^mmmm 




MODERN 
DIAGNOSIS AND TREATMENT 

OP 

Diseases of Children 



A TREATISE ON THE MEDICAL AND SURGICAL DISEASES 

OP INFANCY AND CHILDHOOD, WITH ESPECIAL 

EMPHASIS UPON CLINICAL DIAGNOSIS 

AND MODERN THERAPEUTICS. 



Practitioners and Students of Medicine 



BY 

HERMAN B. SHEFFIELD, M.D. 

(Co-Aut-hor of "Practical Pediatrics") 

Instructor in Diseases of Children at the New York Post-Graduate Medical School and 

Hospital; Visiting: Physician (Diseases of Children) to the Yorkville Dispensary 

and Hospital for Women and Children, and to the German Poliklinik ; 

Fellow of the New York Academy of Medicine ; Associate 

Editor of the Centralblatt f. Kinderheilkunde, etc. 



With One Hundred and Fifty Original Half=tone Photo= 

engravings and Numerous Smaller Illustrations, 

Some to Colors 




PHILADELPHIA 
F. A. DAVIS COMPANY, Publishers 
1911 



COPYRIGHT. 1911 

BY 

F. A. DAVIS COMPANY 
[Registered at Stationers' Hall, London, Eng.] 



Press of F. A. Davis Company 

1914-16 Cherry Street 

Philadelphia. Pa. 



TO 

AUGUSTUS CAILLE, M.D. 

Professor of Pediatrics 

AND 

HENRY T. BROOKS, M.D. 

Professor of Patholog-y 

THIS VOLUME IS AFFECTIONATELY INSCRIBED 

As a Tribute to Their Noble Character and High 
Professional Attainments, and in Appre- 
ciation of Their Friendship 

BY THE AUTHOR 



MODERN 
DIAGNOSIS AND TREATMENT 

OF 

Diseases of Children 



A TREATISE ON THE MEDICAL AND SURGICAL DISEASES 

OF INFANCY AND CHILDHOOD, WITH ESPECIAL 

EMPHASIS UPON CLINICAL DIAGNOSIS 

AND MODERN THERAPEUTICS. 



Practitioners anb Students of Medicine 

BY 

HERMAN B. SHEFFIELD, M.D. 

Instructor in Diseases of Children at the New York Post-Graduate Medical School and 

Hospital; Visiting Pnysician (Diseases of Children) to the Philanthropin Hospital, 

Northwestern Dispansary and the German Poliklinik ; Associate. 

Babies' Hospital Dispensary; Fellow of the New York 

Academy of Medicine; Associate Editor of the 

Centralblatt f. Kinderheilkunde, etc. 



SECOND EDITION 



With Two Hundred and Seven Illustrations, Most of Them 
Original HaIf=tone Photoengravings, Some in Colors. 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 

1912 



T) 



COPYRIGHT. 1911 
COPYRIGHT. JUNE. 1912 

BY 
F. A. DAVIS COMPANY 

[Registered at Stationers* Hall, London. En?.] 



Philadelphia, Pa., U. S. A. 

Press of F. A. Davis Company 

1914-16 Cherry Street 



€^CI.A3166I7 



PREFACE TO SECOND EDITION. 



In the present edition I have endeavored to improve upon 

the cHnical features of the book by incorporating the most recent 

diagnostic and therapeutic advances and the numerous valuable 

suggestions of the reviewers of the first edition. A special article 

has been added on Primary Family Splenohepatomegaly, and 

several engravings have been replaced by new ones which more 

typically illustrate the symptomatology of the respective diseases. 

I trust the new edition will continue to merit the confidence and 

good will of the profession. 

H. B. S. 



Xew York City. 
127 West 87th St. 



PREFACE. 



This volume is pre-eminently a clinical treatise on the 
medical and surgical diseases of infancy and childhood, 
embodying also the essentials of the theory of pediatrics so as 
to meet the needs of both the medical student and general 
practitioner. It is based chiefly upon the author's very 
extensive personal experience in hospital, dispensary and 
private practice, and presents an amplitude of observations, 
which is obtainable only in large cosmopolitan centers of 
population like Greater New York. 

The time-worn, stereotyped, verbatim quotations of 
different authors, and the customary overabundance of illus- 
trations of fads and fancies of enterprising tradesmen — which 
so conveniently help to "pad" a great many of our text-books 
— have been entirely eliminated. The valuable space thus 
gained has been utilized for an ample array of carefully 
selected photographs and notes to illustrate and emphasize 
the most important diseased conditions as met in actual 
practice. 

In addition to less important innovations throughout the 
book, the author has ventured to introduce material changes, 
especially in the following subjects: Feeble vitality of the 
newly born ; hsemorrhoea congenita et acquisita ; microceph- 
alus ; infant feeding; gastroenterocolitis ; acute meningitis; 
tuberculosis and tetanism. Furthermore, special chapters 
are devoted to physical diagnosis and semeiology, general 
and special therapeutics, congenital malformations, and mental 
diseases — matters of great importance which have thus far 
received but little attention in current pediatric literature. 

Finally, side-notes are appended to enable especially the 
medical student at a glance to grasp the most essential points 
of interest of the subjects under discussion. 

We are greatly indebted to our publishers, F. A. Davis 
Company, for their unselfishness and unusual skill with which 
they have executed the numerous suggestions of the author in 
the general make-up of the book. 

New York City. H. B. S. 



CONTENTS. 



CHAPTER I. PAGE 

Examination of the Patient 1 

Past and present history of patient 1 

Physical examination of the 

Head and its contents 4 

Neck and throat 16 

Thorax and its contents 17 

Abdomen and its contents 36 

Urogenital system 44 

Vertebral column 50 

Extremities 51 

Weight and length of the child 57 

CHAPTER H. 

Prevention and Control of Disease 59 

Nutrition 61 

Hygiene and sanitation 82 

Immunization and biologic diagnosis and therapeutics 91 

Materia medica and physical therapeutics 102 

CHAPTER HI. 

Congenital Malformations of 

Head and its contents 123 

Neck and throat 134 

Thorax and its contents 135 

Abdomen and its contents 136 

Urogenital system 148 

Vertebral column 154 

Extremities 157 

CHAPTER IV. 

Birth Injuries 159 

Superficial structures 159 

Deep structures 160 

CHAPTER V. 

Diseases of the Newly Born 165 

Feeble vitality of the nev^^ly born 165 

Sepsis neonatorum 172 

Functional disorders 183 

CHAPTER VI. 

Diseases of the Alimentary Tract 185 

Diseases of the mouth 185 

Diseases of the esophagus 191 

Diseases of the stomach and intestines 193 

Intestinal parasites 222 

(vii) 



viii CONTENTS. 

CHAPTER VII. PAGE 

Diseases of the Liver 230 

CHAPTER VIII. 

Diseases of the Respiratory System 235 

Diseases of the nose, throat and ear 236 

Diseases of the lungs and pleura 259 

CHAPTER IX. 

Communicable Diseases 287 

Exanthemata 287 

Tuberculosis 351 

Diseases of the bones and joints 374 

Syphilis 398 

Malaria 410 

Rheumatism and allied affections 415 

CHAPTER X. 

Diseases of the Heart 428 

Congenital 428 

Acquired 433 

CHAPTER XI. 

Diseases of the Kidneys, Bladder, Etc 447 

Diseases of the kidneys 447 

Diseases of the bladder 458 

Diseases of the genitalia 463 

CHAPTER XII. 

Diseases of the Blood and Ductless Glands 470 

Diseases of the blood 470 

Diseases of the spleen 481 

Diseases of the thymus gland 482 

Diseases of the thyroid gland 485 

CHAPTER XIII. 
Disturbances of Metabolism 493 

CHAPTER XIV. 

Diseases of the Nerve System 512 

Diseases of the brain 512 

Diseases of the cord 527 

Diseases of the peripheral nerves 541 

Muscular atrophies and dystrophies 545 

General spasmodic affections 549 

CHAPTER XV. 
Mental Diseases 570 

CHAPTER XVI. 
Skin Diseases 591 

Index 607 



LIST OF ILLUSTRATIONS. 



FIG. PAGE. 

1. Top View of the Foetal Skull (Grandin, Jarman and Marx) 3 

2. Posterior View of the Foetal Skull (Grandin, Jarman and Marx). 4 

3. Diagram of the Visual Tract 9 

4. First (Milk) Set of Teeth (Starr) 13 

5. The Thoracic and Abdominal Regions 18 

6. The Regions of the Back 19 

7. Diagnostic Lines of the Thorax 22 

8. Anterior Boundaries of the Lungs 23 

9. Posterior Boundaries of the Lungs 24 

10. Skiagram of Normal Heart. 29 

11. Topography of the Heart 30 

12. 13, 14. The Relative and Absolute Heart Dullness at Different 

Ages 31 

15. Location of Heart-apex at Different Ages 32 

16. Topography of Cardiac Valves 34 

17. The Thoracic and Abdominal Regions 37 

18. Topography of the Liver and Spleen 38 

19. Topography of Kidneys, Spleen and Liver 39 

2C. Severe Acute Nephritis (Lenharts) 47 

21. Weight Chart • • 58 

22. Microscopical Appearances of Woman's Milk (After Fleisch- 

man) 61 

23. Breast Pump 63 

24. Holt's Milk Set 64 

25. Chapin's Dipper for Removal of "Top-milk" 70 

26. Arnold Steam Sterilizer 71 

27. Stages in VVidal Reaction (After Robin) 102 

28. Stomach Tube 107 

29. Microcephalus — brain disease 1 23 

30. Microcephalus — miniature brain 124 

31. Congenital Hydrocephalus 125 

32. Hare-lip 129 

33. Bilateral Anophthalmia 131 

34. Megacolon Congenitum 140 

35. Congenital Absence of Scrotum and its Contents, Anus and 

Rectum 141 

36. Stomach and Intestines of Case Fig. 35 142 

37. Diastasis Recti Abdominis 143 

38. Umbilical Hernia 144 

39. Thoracoabdominopagus, with Ectopia Viscerum 145 

40. Skiagram of Thoracoabdominopagus 146 

41. Congenital Hydrocele, Communicans 152 

42. Myelocystocele 155 

43. Congenital Talipes Varus 158 

(ix) 



LIST OF ILLUSTRATIONS. 



FIG. 



PAGE. 



44. Obstetric Facial Palsy 161 

45, 46. Bilateral Obstetric Brachial Paralysis 162, 163 

47. Obstetric Brachial Paralysis 164 

48. Incubator for Premature Infants 169 

49. Incubator Room for Newly Born Babies with Feeble Vitality 170 

50. Gonococcus. (Gonorrhoeal Pus.) (colored) (Lenhartz and 

Brooks) 175 

51. Bacillus Tetani (After Frdnkel and Pfeiffer) 179 

52. Ulcerative Stomatitis 186 

53. Gastroenterocolitis Chronica 201 

54. Prolapsus Recti 211 

55. Oxyuria Vermicularis (After Leuckart) 223 

56. Taenia Saginata (Partly after Leuckarf) (Lenharts) 223 

57. Taenia Solium (After Leuckart) 225 

58. Bothriocephalus Latus (After Leuckart) 225 

59. Taenia Nana (After Leuckart) 226 

60. Taenia Echinococcus of the Dog (After Leuckart) 227 

61. Ankylostomum Duodenale (After Leuckart) 228 

62. 6Z, 64. Primary Family Splenohepatomegaly 232, 233 

65. Tonsillotome 243 

66, 67, 68. Adenoids 244, 245, 246 

69. Adenoid Curette 247 

70. Retropharyngeal Abscess 249 

71. Diplococcus Pneumoniae (Pneumococcus) (colored) (Lenhartz 

and Brooks) 266 

72. Fever Curve of Typical Lobar Pneumonia 267 

7?>. Fever Curve of Fatal Apex Pneumoniae 268 

74. Pneumothorax 284 

75, 76. Pneumohypoderma 285, 286 

77. Influenza Bacilli (colored) (Lenhartz and Brooks) 287 

78. Fever Curve of Atypical Influenza 288 

79. Paralysis of the N. Abducens 289 

80. Diphtheria or Klebs-Loffler Bacilli (colored) (Lenhartz and 

Brooks) 297 

81. Introducer with Tube and Detached Obturator 306 

82. Extubator 307 

83. Mild Discrete Small-pox (Schamherg) 324 

84. Fatal Small-pox (Schamberg) 325 

85. Fever Curve of Typhoid Fever 329 

86. Fever Curve of Tuberculous Meningitis 2)2>7 

87. Lumbar Puncture 339 

88. Bilateral Epidemic Mumps 345 

89. Tubercle Bacilli and Micrococcus Tetragenus (sputum) 

(colored) (Lenhartz and Brooks) 352 

90 to 94. Breathing Exercises 353 

95. Acute Pulmonary Miliary Tuberculosis (Langerhans) 356 

96. Miliary Tuberculosis (skiagram) 357 

97. Tuberculosis (Ziegler) 359 

98. Phthisis Pulmonum 362 

99. Tuberculosis of the Brain 366 



LIST OF ILLUSTRATIONS. xi 

FIG. PAGE, 

100. Tuberculous Peritonitis 367 

lOL Tubercular Infiltration (Leedham-Green) 371 

102. Tubercular Ulcer (Leedham-Green) 371 

103. Bladder Tuberculosis of Left Kidney (Wyatt) 371 

104. Tuberculous Axillary Lymphadenitis Z7?> 

105. Tuberculous Disease of the Elbow-joint 375 

106. Pott's Disease (Langerhans) 376 

107. 108. Cervical Spondylitis 377, 378 

109, 110. Dorsal Spondylitis 379, 380 

111, 112. Lateral Spinal Curvature 382, 383 

113. Rachitic scoliotic skeleton (Grandin, Jarmaii and Marx) 384 

114. Paralytic Scoliosis 385 

115. 116. Lateral Spinal Curvature 386, 387 

117, 118. Hip-joint Disease 388, 389 

1 19. Sarcoma of the Femur 390 

120. Tuberculous Disease of the Knee-joint 391 

121. Spina Ventosa 393 

122. Osteomyelitis of Tibia (Senn) 395 

123. Osteomyelitis of the Radius (Senn) 397 

124. 125, 126. Congenital Syphilis 398, 399, 400 

127. Pemphigus Syphiliticus 401 

128. Syphilitic "Hutchinson Teeth" 405 

129. Syphilitic Osteoperiostitis of the Tibiae 406 

130. Malaria Plasmodia ; Tertian Type (colored) (Lenhartz and 

Brooks) 410 

131. Temperature Chart of Quotidian and Tertian Malarial Fever 411 

132. Rheumatic Polyarthritis 416 

133. 134. Rheumatic Torticollis 418, 419 

135. Multiple Exostoses 426 

136. Vitium Cordis. "Morbus Coeruleus" 429 

137. Dextrocardia 432 

138. Fever Curve of Malignant Endocarditis 438 

139. Acute Hemorrhagic Nephritis (Lenhartz and Brooks) 448 

140. 141. Acute Nephritis with General Anasarca 449, 450 

142. Sarcoma of the Kidney 457 

143. Precocity 469 

144. 145. Pseudoleukemia Infantum Splenica 473, 474 

146. Acute Leukemia (Lenhartz and Brooks) 475 

147. Progressive Pernicious Anemia (Lenhartz and Brooks) 476 

148. Large Thymus (skiagram) 483 

149. Goiter 486 

150. Cystic Goiter ..487 

151. Congenital Cretinism 488 

152. 153, 154. Sporadic Cretinism 489, 490, 491 

155. Marasmus 494 

156. Rachitic Frons Quadrata and Curvature of Spine 497 

157. Rachitic Beading of Ribs, "Pot-belly" and Bowlegs 498 

158. Rachitic Kyphosis 499 

159. Rachitic Bowlegs, "Jug"-shaped Abdomen, and Separation of 

Epiphyses 500 



xii LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

160. Rachitic Knock-knees 501 

161. Achondroplasia 505 

162. Moeller-Barlow's Disease 506 

163. 164. Adipositas 510, 511 

165. Acquired Hydrocephalus, Following Acute Gastroenterocolitis 517 

166. Polioencephalitis 520 

167. Encephalitis, with Left Hemiplegia 523 

168. Anterior Poliomyelitis, Involving Right Arm 529 

169. Poliomyelitis, Involving Right Leg 530 

170. Poliomyelitis, Involving the Neck 531 

171. Anterior Poliomyelitis, Affecting Right Leg 532 

172. Paralytic Equinovarus in Poliomyelitis 533 

173. Anterior Poliomyelitis, Involving Extremities, Face and Abdom- 

inal Muscles 534 

174. Little's Disease 539 

175. Peripheral Facial Paralysis — Bell's Palsy 541 

176. 177, 178. Pseudohypertrophic Paralysis 546, 547 

179, 180, 181, 182, 183. Tetanism 556, 557, 558, 559 

184. Tetany 561 

185. Hydrocephalic Idiot 575 

186. 187. Microcephalic Idiot. Amaurotic Idiot 576 

188. Mongolian Idiocy. (Calmuck type) 577 

189. Mongolian Idiocy. (Malay type) 578 

190. Cretinic Idiot 579 

191. Paralytic Idiot 580 

192. 193. Infantilism 581 

194. Skiagram of Wrist of Normal Child 582 

195. Skiagram of Wrist of Idiot 582 

196. Amaurotic Family Idiocy 583 

197. The Normal Fundus of the Right Eye (Henle) 583 

198. Macular Change (cherry-red color) in Amaurotic Family Idiocy 

(Tay) ". 584 

199. Seborrheic Eczema of Head and Face 592 

200. Psoriasis 596 

201. Psoriasis of the Legs (Shoemaker) 597 

202. Herpes Zoster , 598 

203. Phthirius Pubis (Crab-louse) (After Landois) 601 

204. Sarcoptes Scabiei (After Gudden) 502 

205. Trichophyton Tonsurans (After Bizzozero) 603 

206. Tinea Tonsurans (Shoemaker) 504 

207. Achorion Schonleinii (After Bizzozero) , . 505 



CHAPTER I. 
Examination of the Patient. 



Systematic and thorough examination of the patient is the 
keynote to successful diagnosis and treatment. In infants 
particularly the physical examination calls for a great deal of 
patience, care, and scrutiny, and while gentleness in handling 
the patient is certainly to be preferred, ofttimes firmness will 
succeed, where kindness utterly fails. Before, or while, pro- 
ceeding with the physical examination of the patient, an effort 
should be made to be informed on the following points of 
interest : — 

Family history — 

Longevity of the parents, brothers and sisters ; the dis- 
eases they suffered from, especially as to tuberculosis, rheu- 
matism, heart, kidney or liver disease, alcoholism, epilepsy, 
insanity, etc. ^Miscarriages in the mother. 

Past personal history of the patient — 

Degree of maturity at birth, and mode of delivery 
(instrumental or otherwise) ; condition soon after birth, par- 
ticularly as to signs of traumatism, convulsions, asphyxia, 
deformity, hemorrhages, skin eruptions, nasal catarrh 
("snuff] es'') ; the diseases the patient suft'ered from at a later 
period, e.g., gastro-intestinal, exanthematous, pulmonary ; 
otitis, rheumatism, bone affections, etc. Mode of feeding 
(breast or bottle) ; gain or loss of weight ;i time of eruption 
of temporary or permanent teeth ; the time when the 
patient began to sit up, stand, creep, and walk. Pecul- 
iarities of temper, etc. 



1 See page S7. 

1 (1) 



2 EXAMINATION OF THE PATIENT. 

Present history of the patient — 

Age of patient. 

Mode of onset of the disease (gradual or sudden). 

F'ever (continuous, remittent or irregular). 

Convulsions^ (apparent cause ; time of occurrence ; dura- 
tion). 

Vomiting^ (during, after, or between meals ; appearance of 
vomit). 

Skin eruption (location, duration; desquamation). 

Diarrhea^ (duration; frequency and appearance of the 
stools). 

Constipation^ (acute or habitual; appearance of the stools). 

Pain (situation, duration; degree of severity). 

Cough^ (duration; paroxysmal or croupy ; appearance of 
sputum). 

Dyspnea'^ (worse after fatigue or at night; sudden). 

Cyanosis^ (duration; mode of onset, — with convulsions). 

Urinary disturbance^ (enuresis, dysuria ; suppression; ap- 
pearance of urine). 

Disturbance of sleep (pavor; snoring; twitching). 

Behavior and mental capacity (recent change; truancy). 

Condition of special senses^^ (defective vision, hearing,, 
etc.). 

Intelligent response to the aforementioned questions on 
the part of those in charge of the patient, will materially aid 
in the diagnosis. 

It will be found of advantage to keep a brief but comprehen- 
sive record of the history and condition of the patient at the time 
of examination, and of the further course of the disease. The 
different so-called card systems in vogue generally answer this 
purpose admirably, especially in private practice. 



- See page 52. "' See page 24. 

3 See page 41. ^ See page 7. 

4 See page 42. ^ See page 44. 

•'> See page 42. i^ See pages 8, 9 and 10. 
c See page 27. 



PHYSICAL EXAMINATION. 3 

PHYSICAL EXAMINATION. 

The history-taking completed, we next turn to the physi- 
cal examination of the patient. This should be systematic, 
preferably with the child entirely undressed, and if deemed 




Fig. 1. — Top View of the Foetal Skull (showing the Ante- 
rior Fontanelle and the Frontal, Coronal, and Sagittal Sutures). 
{Grandin, Jarman and Marx.) 

necessary, should include inspection, palpation, auscultation, 
percussion, mensuration and weighing. 

We usually begin with the examination of the head, 
noting its size and shape, the condition of the bones of the 



4 EXAMINATION OF THE PATIENT. 

skull, its fontanelles and sutures, itg" attitude ; facial expression 
and hue ; the condition of the nose, eyes, ears, mouth, lips, 
tongue, teeth and pharynx. 

THE HEAD. 

The head is rarely normal in shape immediately after birth. 
The scalp is swollen, the bones are often displaced, and here 




Fig. 2. — Posterior View of the Foetal Skull (showing the 
Posterior Fontanelle and the Lambdoidal and Sagittal Sutures). 
{Grand ill, Jar man and Marx.) 

and there are bruises and ecchymoses, the results of a long and 
painful journey. Within about a week, the swelling subsides, 
the bones adjust themselves, the head becomes round or oval 
and smooth except for the markings of the fontanelles and 
sutures. 

The cranial circumference (fronto-occipito diameter) soon 
after l:)irth measures about thirteen inches. The skull enlarges 



Tf^E SKULL. .") 

rapidly up to six months old — seventeen inches; then more 
slowly about one inch every year up to hve years — tw^enty-one 
inches ; it then remains stationary in growth up to adult life, 
when it measures from twenty-two to twenty-three inches. 

The posterior fontanel J c closes by the end of the second 
month, the anterior when the infant is about eighteen months 
old, at the latest. 

A healthy baby is able to hold the head erect when about 
four months old. 
The skull is — 

Asymmetrical, wnth depressions and protrusions, in caput 
succedaneum ; meningo- and encephalo-cele ; syphilis ; 
neoplasms ; abscesses, etc. 
Large, in hydrocephalus ; hypertrophy of the brain ; rachitis. 
Small, in microcephalus ; porencephalia. 
The fontanelles are — 

Closed late, in hydrocephalus ; rachitis ; cretinism ; idiocy ; 

osteogenesis imperfecta. 
Closed prematurely, in microcephalus ; atrophy of the brain. 
Distended, in active and passive congestions of the brain, 
e.g., diverse forms of meningitis ; meningismus ; liydro- 
cephaloid ; intracranial tumors ; cerebral hyperemia. 
Sunken, in wasting diseases ; after great loss of body fluids ; 
after lumbar puncture. 
The cranial bones are — 

Soft and thin, in chronic hydrocephalus ; craniotabes. 
Hard and thick, in syphilis ; exostosis. 
The sutures are — 

Widely separated, in hydrocephalus ; intracranial tumors. 
Prematurely closed, in microcephalus. 
Attitude. The Head is— 

Retracted, in general debility ; macrocephalus ; hydro- 
cephalus ; amaurotic family idiocy. 
Spasmodically retracted (opisthotonos), in meningitis; 

meningismus ; encephalitis ; apical pneumonia. 
Turned laterally, in torticollis ; hematoma of the sterno- 
cleidomastoid muscle ; retropharyngeal abscess ; cer- 
vical spondylitis ; cervical adenitis ; mastoiditis. 
Moving irregularly, in hyperpyrexia ; spasmus nutans ; 
chorea; habit spasm. 



6 EXAMINATION OF THE PATIENT. 

THE FACE. 
Fades dolorosa — 

Continuous pain (eyes open, face wrinkled, mouth half 
closed and drawn to one side, moaning and whining), 
in diverse acute inflammatory diseases, e.g., pneumonia, 
pleurisy, rheumatism, appendicitis. 

Intermittent pain (face distorted, red, perspiring; loud cry- 
ing, tossing, kicking), in colic, dysuria, etc.; vertebral 
caries (''starting pain"). 
Facies luctuosa — 

Face of sorrow (forehead and face wrinkled, face pale, 
emaciated, indifferent, apathetic, eyes half closed) in 
chronic wasting diseases, especially tuberculosis, and 
last stage of heart disease. 
Facies anxiosa — 

Face of anxiety (eyes glistening, congested, red or livid, 
and perspiring; alae nasi active) in orthopnea from 
various causes, e.g., laryngeal stenosis, extensive pneu- 
monia, pulmonary edema; in hysteria. 
Facies Hippocratica — 

Face of grave abdominal distress, or extreme exhaustion 
(face pale, contracted, corneae dull, eyeballs and temples 
deeply sunken, nose pinched, lips dry, cyanotic, and 
covered with sordes), in moribund state, collapse, 
cholera nostras, peritonitis, etc. 
Facies meningitidis — 

Face of internal convulsions (staring look into distance, 
glassy corneae, rapidly changing complexion of the 
face), in meningitis; severe eclampsia. 
Facies senilis — 

Face of extreme old age (shriveled facial muscles and skin, 
pointed nose, lusterless eyes), in marasmus; syphilis; 
chronic hydrocephalus. 
Facies idiotes — 

Face of the mentally defective (senile features, open mouth, 
protruding tongue) in all forms of idiocy and imbe- 
cility ; less marked in adenoids. 
Facies sardonica — 

Face of facial muscular spasm (peculiar "grin," proboscis- 
form mouth, sometimes foamy) in tetanus and similar 
prolonged convulsive conditions. 



THE EYES. 7 

See also "Facial Paralysis," "Facial Hemiatrophy," ''Per- 
tussis." 
Facial hue — 

Livid, in congenital and acquired heart disease ; in pro- 
nounced respiratory difficulty, e.g., laryngeal stenosis, 
pulmonary edema, asthma, etc.; in cerebral hyperemia; 
sinus thrombosis; in "holding the breath." 

Pale, in anemia; in acute and chronic wasting diseases; 
sudden pallor, in collapse, e.g., from exhausting hemor- 
rhage. 

AA'axy, in chronic malaria ; suppurative processes ; chronic 
nephritis ; malignant disease. 

Yellow, in icterus neonatorum or catarrhalis ; congenital 
obliteration of the bile duct; in Buhl's or Winckel's dis- 
ease ; in liver affections, especially due to syphilis. 

Purplish, in phthisis pulmonalis ("hectic flush"), hyper- 
pyrexia; pneumonia; compensating heart disease. 

Greenish, in chlorosis. 

Copper-color {e.g., on forehead), in syphilis. 

Bronze color, in Addison's disease. 

See also "Exanthemata" and "Skin Diseases." 

THE EYES. 
The eyelids are — 

Edematous, without local inflammation, in anemias; heart 
and kidney diseases; pertussis. 

Crusty, red and swollen, in acute and chronic inflammation 
of the eyelids ; in pediculosis of the eyelashes ; in con- 
genital syphilis (in conjunction with rhagades at the 
canthi, and purulent nasal discharge) ; in scrofulosis 
(with keratitis, excoriation of the upper lip, and 
adenitis) ; red and Avatery, in nasal catarrh, hay fever, 
and measles. 

Retracted, inability to loAver upper lid, from loss of power 
in the palpebral muscles, in facial paralysis. 

Drooping (ptosis) of upper lid, from inability to raise it, in 
congenital defects of the palpebral levators or their 
nerve supply; in local trauma; in oculomotor paralysis. 

Spasmodically contracting, in local inflammatory processes 
of the lids; in spasmodic affections, such as chorea and 
tic ; in divers forms of meningeal irritation. 



8 EXAMINATION OF THE PATIENT. 

The eyeballs are — 

Congested, in inflammatory processes of the eye, e.g., kera- 
titis ; in meningitis ; asphyxia. 

Protruding, in exophthalmic goiter; in neoplasms (gum- 
ma) ; in chloroma (frog-like appearance). 

Immobile, partially or completely, in ophthalmoplegia. 

Turned laterally (strabismus, squint) ; in errors of refrac- 
tion; in paralysis of the abducens (convergent strabis- 
mus) ; in paralysis of the oculomotor (divergent stra- 
bismus — with ptosis, mydriasis, and diplopia). 

Oscillating (nystagmus), in hereditary ataxia; lesions of 
the corpora quadrigemina ; multiple sclerosis ; menin- 
gitis ; sinus thrombosis; hydrocephalus. 
The pupils are — 

Contracted, unilaterally, in paralysis of cervical sympa- 
thetic, e.g., migraine, cervical rib ; in pressure by central 
tumor. Bilaterally, in affections of the cervical cord, 
both sides ; early stage of meningitis ; from the effects 
of opium and its derivatives, chloral, pilocarpin, physo- 
stigmin, etc. 

Dilated, unilaterally, in irritation of the cervical sympa- 
thetic, e.g., migraine ; in oculomotor paralysis. Bilat- 
erally, in marked dyspnea ; collapse ; from the effects 
of atropine, belladonna, hyoscyamus, cocaine, etc. 

Unequal, in unilateral contraction or dilatation, as afore- 
mentioned ; in unilateral pontine lesion, and in apo- 
plexy. 

Immobile, in adhesions of the iris to the lens; in eclampsia; 
in lesions of the corpora quadrigemina; in tabes dor- 
salis (immobility to light, but responding to accommo- 
dation — Argyll-Robertson pupil). 
Vision is — 

Diminished, in errors of refraction ; miosis ; mydriasis ; hys- 
teria ; acute eye affections, e.g., iritis, retinitis, etc. ; in 
corneal opacities, etc. ; congenital eye defects, e.g., 
albinism, irideremia ; in toxic amblyopia, e.g., overdoses 
of quinine, tobacco; congenital amblyopia (usually 
unilateral) ; optic neuritis. 

Lost, temporarily or permanently, in uremic, diabetic, or 
other forms of toxemia; in severe convulsions of cen- 
tral origin ; congenital cataract ; amaurotic family 



THE EARS. 9 

idiocy (gradual onset) ; in embolism of the central 
retinal artery (unilateral) ; local injuries; optic atrophy. 

Double (diplopia), in peripheral palsies of the eye muscles, 
e.g., after diphtheria, influenza, herpes zoster ophthal- 
micus (unilateral) ; in strabismus. In orbital palsies, 
through outside pressure, e.g., neoplasms. In central 
palsies (afifecting the eye on the opposite side). In 
nuclear palsies, e.g., of the abducens (involving the 
eye on the same side). 

Half, i.e., blindness of one-half of the visual field (hemia- 
nopia) : lateral or homonymous, in lesions of the optic 
tract between chiasm and cortex; temporal, in dis- 
ease of the optic chiasm affecting the anterior or pos- 
terior angles ; nasal, in disease of the chiasm afTecting 
the outer angles. (See Fig. 3.) 




Fig. 3. — Diagram of the Visual Tract. iV. Lesions producing 
nasal hemianopia. L. Lesions producing lateral hemianopia. T. 
Lesions producing temporal hemianopia. {Sheffield.) 



THE EARS. 

Abnormalities of the ear and adjacent structures- 
Asymmetry of the ears, in congenitally, mentally defectives. 
Tumefactions, at and about the ear : In the external 
meatus, in furuncles, abscesses, and local traumatism. 
In front of the ear, in epidemic parotiditis (often bilat- 
eral, though not simultaneously) ; in secondary paro- 
titis (complicating diseases of the mouth; local infec- 
tion in the vicinity; acute infectious diseases, e.g., 
typhoid) ; in new growths. Behind and downward, 
pushing the auricle forward, in mastoiditis ; in per- 
forating abscess of the external auditory canal ; in pre- 



10 EXAMINATION OF THE PATIENT. 

auricular lymphadenitis ; and much less marked in 
glandular fever. 
Hearing is — 

Diminished, at a distance, but not by bone conduction, in 
external and middle ear disease; in occlusion of the 
auditory canal by foreign bodies, e.g., cerumen, fu- 
runcles; or outside tumors, e.g., parotitis; in naso- 
pharyngeal disease, e.g., adenoids. 

Lost, temporarily or permanently, both at a distance and 
by bone conduction, in congenital defects of auditory 
apparatus ; in compression (by intracranial tumors) or 
atrophy of the auditory nerve ; in disease of the pons 
or cerebellum which has spread to the fourth ventricle ; 
in amaurotic family idiocy (late). 

Disturbed by noises (tinnitus aurium), in foreign bodies in 
the auditory canal, e.g., cerumen, mycosis, myringitis ; 
in catarrh of the Eustachian tube; in otitis media; 
neuroses; epilepsy, and mental affections. 

THE NOSE. 

Abnormalities of the nose in structure and function — 

Saddle-shaped, sunken, in hereditary syphilis ; in trauma- 
tism. 

Compressed and pointed, in nasal obstruction, chiefly 
adenoids. 

Pinched and pale, in collapse; sudden fright; phthisis pul- 
monum. 

Purplish in color, in circulatory and respiratory difficulties, 
e.g., pneumonia, heart disease. 

Hyperactivity of the alse nasi, in grave dyspnea. 

Nasal voice or cry, in nasal obstruction, e.g., in adenoids, 
rhinitis, retropharyngeal abscess ; in diphtheritic paral- 
ysis ; in ulceration of the nasal bones, especially in 
syphilis. 
Nasal discharge — 

Serous, transparent, later mucous, in acute simple rhinitis 
C'cold") ; measles; hay fever. 

Serosanguinolent, later purulent, in diphtheritic, scarlatinal, 
and syphilitic rhinitis ; in the presence of foreign 
bodies in the nose ; in scrofulosis. 



THE MOUTH. 11 

IMucopurulent or purulent, in severe acute rhinitis; in 
putrid infection. 

Hemorrhagic (epistaxis), in nasal trauma; inflammation of 
the nasal mucosa; nasal polypus; adenoids; hemo- 
philia ; vicarious menstruation ; passive congestion of 
the brain; increased vascular tension, e.g., hyper- 
pyrexia (especialh' if sudden, as it is apt to be at the 
onset of exanthematous diseases), heart and lung dis- 
eases, pertussis; in diseases of the blood, e.g., sepsis; 
leukemia, etc. 

The lips are- THE LIPS. 

Excoriated (upper lip) from acrid nasal discharge, in acute 
and chronic affections of the nose, e.g., rhinitis, ade- 
noids ; in scrofulosis ; syphilis. 

Covered by herpes, a vesicular eruption (usually upper lip 
at angle of mouth), in ordinary ''colds" ; in pneumonia ; 
in meningitis cerebrospinalis. 

Cracked and scarified, especially at the angles of the mouth, 
in syphilis hereditaria; but also in burns (usually 
unilaterally). 

Covered by sordes, in septic infections ; in typhoid fcA'er. 

Rosy in color, in good health. 

Deep red, in compensating heart disease. 

Purple, in marked dyspnea, from respiratory and circula- 
tory disturbance. 

Pale, in divers forms of anemia. 

Livid, in heart failure. 

Dirty, soot-like, in sepsis; typhoid fever; ulcerative stoma- 
titis. 

The mouth is- ™E MOUTH. 

Drawn to one side, droops, in facial paralysis, especially 
when the facial muscles are brought in action; in pro- 
gressive facial hemiatrophy; in hemiplegia. 

DraAvn outward and downward, Avith the lips pointed for- 
Avard, proboscis-like, in trismus neonatorum, tetanus 
and tetany. 

Broad, grinning, in cretinism ; idiocv. 

Large from birth, in macrostoma. 

Small and contracted, in microstoma ; in congenital syph- 
ilis ; from the efi:"ects of burns. 



12 EXAMINATION OF THE PATIENT. 

Open habitually ("mouth-breathing"), in nasal obstruc- 
tion; adenoids; idiocy; in retropharyngeal abscess. 

Twitching spasmodically, chorea ; habit spasm. 
Foetor ex ore — 

Stale insipid, in catarrh of the nasopharynx; dental caries; 
in febrile diseases ; chronic dyspepsia. 

Putrefactive, at short range, in diverse forms of simple 
stomatitis ; acute indigestion. At a distance, in noma ; 
malignant diphtheria or scarlatinal angina. 

Sulphuretted hydrogen odor, in fetid bronchitis ; pulmonary 
gangrene. 

Aceton odor, in diabetes ; cyclic vomiting. 

Ammoniacal odor, in uremia. 

Chloroform, ether, alcohol, etc., odors, from the effects of 
these drugs. 



THE ORAL CAVITY. 

In irritable children it is preferable to postpone the exam- 
ination of the mouth-cavity until the other portions of the 
body have been thoroughly examined, since the undue excite- 
ment usually created by the inspection and palpation of the 
mouth and throat of the patient greatly interferes with erudi- 
tion of the other physical phenomena. Through daily prac- 
tice, the physician soon learns almost at a glance to distinguish 
the abnormal from the normal ; until he has acquired this skill, 
however, he should examine the contents of the oral cavity 
slowly and systematically. 

The gums, teeth, floor and roof of the mouth ; the tongue, 
buccal mucous membrane, the uvula, fauces, tonsils and pos- 
terior pharynx — all should receive careful attention. 
The gums are — 

Whitish, thin, and hard, normally in early infancy. 

Reddened, slightly swollen and painful to touch, before 
eruption of teeth. 

Spongy, swollen, and prone to bleed, in divers forms of 
stomatitis ; in scurvy ; purpura ; in other grave consti- 
tutional diseases, such as leukemia. 

Purulent, receding from the teeth, in p3^orrhea ah'eolaris 
(Riga's disease) ; alveolar abscess. 

Bleeding, without inflammatory symptoms, in hemophilia. 



THE TEETH. 



18 



Colored blue, forming a blue line along the margin of the 
gum, in lead poisoning. 
The temporary teeth are twenty in number, and under normal 
conditions generally appear in groups, at variable in- 
tervals, as follows : — 
Two lower central incisors at the age of from 6 to 8 months. 
Four upper incisors (2 central, 2 lateral), from 8 to 10 

months. 
Two lower lateral incisors, from 11 to 12 months. 




Louver Incisors — fifth to ninth month. 
I'l'per Incisors — eighth to twelfth month. 

Lateral Incisors and First Molars— twelfth to eighteenth month. 
Stomach and Eye Teeth— eighteenth to twenty-fourth momh. 
/A Second Molars — twenty-fourth to thirtieth month. 

Fig-. 4.— First (Milk) Set of Teeth. {^Starr.) 



Four anterior molars (2 upper, 2 lower), from 14 to 16 

months. 
Four canines (2 upper, 2 lower), from 18 to 20 months. 
Four posterior molars (2 upper, 2 lower), from 22 to 30 

months. 
Abnormal teething — 

Dentitio tarda, i.e., considerable retardation (absence of a 

tooth at the age of a year or later), in rickets; general 

debility ; congenital syphilis ; cretinism : idiocy, etc. 
Dentitio precox is of no special significance. Occasionally 



14 EXAMINATION OF THE PATIENT. 

occurs in congenital syphilis (a tooth may appear soon 
after birth) ; in hydrocephalus. 

Irregular implantation, the same as in ''dentitio tarda" 
(q.v.). 
The permanent teeth appear normally in the following order: 

Four first molars (2 upper, 2 lower) at about 6 years. 

Four central incisors (2 upper, 2 lower) at about 7 years. 

F^our lateral incisors (2 upper, 2 lower) at about 8 years. 

Four anterior bicuspids (2 upper, 2 lower) at about 9 years. 

Four posterior bicuspids (2 upper, 2 lower) at about 10 
years. 

Four canines (2 upper, 2 lower) at about 11 years. 

Four second molars (2 upper, 2 lower) at about 12 to 15 
years. 

Four third molars (2 upper, 2 lower) at about 17 to 25 
years. 
Abnormalities of the permanent teeth — 

Increased vulnerability and brittleness, in divers grave con- 
stitutional affections, e.g., rickets, profound anemia ; in 
neglect and injury of the teeth, especially by eschar- 
otic drugs for cleansing of the teeth or medicinal pur- 
poses (e.g., the tincture chlorid of iron, acids). 

Asymmetry, in hare-lip ; cretinism and other forms of de- 
fective mentality; nasal obstruction, ''mouth-breath- 
ing" ; thumb sucking. 

Looseness, in gingivitis ; ulcerative stomatitis ; mercurial- 
ism ; scurvy; pyorrhea alveolaris. 

Hutchinson teeth, i.e., peg'-shaped, dwarfed upper central 
incisors, notched in their cutting edge, in inherited 
syphilis. 
The floor of the mouth may present — 

Adhesio linguae, a frequent cause of difficult suckling; and 
later of difficult speech. 

Sublingual ulcer, in protracted coughing, especially pertus- 
sis. 

New growths, e.g., ranula, fibroma sublingual?e; salivary 
calculi ; inflammatory swelling. 
The palate is — 

Highly arched and asymmetrical, in divers forms of mental 
degeneracy ; adenoids. 

Defective, or perforated, in congenital clefts of the palate ; 



THE TONGUE. 15 

in syphilitic or gangrenous processes (e.g.^ diphtheria, 
scarlatina). 

Red, velvety, in scarlatina. 

Punctiform or stellate, in measles or rotheln. 

Vesicular with red areola, in chicken-pox. 

Papular, in small-pox. 

Whitish-yellow eroded dots, in Bednar's aphthae. 

Minute, yellowish-white milia, in "epithelial pearls." 

White specks or scattered patches, in different forms of 
stomatitis. 

Hemorrhagic and punctiform, in hemorrhagic diathesis ; 
tuberculous and cerebrospinal meningitis ; pernicious 
blood affections. 
The buccal mucous membrane presents, in addition to the dis- 
colorations occurring upon the palate, also the follow- 
ing:— 

Brownish, greenish or grayish ulcer, in incipient noma. 

Red spots with central, rounded, slightly elevated, bluish 
efflorescence (Koplik-Filatov spots), in measles. 
The tongue is — 

Large, in congenital macroglossia; in cretinism; idiocy; 
glossitis. 

Furred, in all acute and protracted forms of gastro-enter- 
itis ; febrile diseases ; nasopharyngeal catarrh. 

Red, in scarlatina (strawberry tongue) ; stomatitis ; glossi- 
tis ; gastritis (hyperacidity). 

Yellow, in biliousness; liver disease. 

Pale, in anemia. 

Gray, brown and somewhat black, with red border and tip, 
in typhoid fever; in sepsis. 

Black, in profound sepsis ; in collapse impending death. 

Livid, in general cyanosis ; congenital heart disease. 

Spotted, desquamating, in geographical tongue ; hyper- 
pyrexia ; stomatitis. 

Fissured, in glossitis desiccans ; hyperpyrexia ; burns. 

Ulcerated, in severe forms of stomatitis ; in syphilis ; tuber- 
culosis ; traumatism (biting of the tongue during an 
epileptic fit; irritation by carious teeth). 

Dry, in mouth-breathing; excessive thirst (e.g., hyper- 
pyrexia, diabetes) ; in sepsis. 

Protruding, in macroglossia (e.g., idiocy, cretinism). 



16 EXAMINATION OF THE PATIENT. 

Drawn to one side, in paralysis of the hypoglossal nerve 
(towards the diseased side) ; in peripheral facial palsy 
(towards the healthy side). 

Tremulous, in hyperpyrexia ; debility ; chorea ; dissemi- 
nated lateral sclerosis ; bulbar paralysis. 
The saliva is — 

Increased in quantity, in mercurialism ; stomatitis; teeth- 
ing; idiotic conditions, and adenoids. 

Diminished in quantity, in fever; from the effects of atro- 
pine, etc. ; parotitis ; glossitis. 
The uvula — 

May be elongated ; the seat of a deposit which may extend 
from the tonsils or from the buccal mucous membrane 
{e.g., stomatitis). 
The tonsils are — 

Enlarged, in divers form of amygdalitis ; diphtheria ; scarla- 
tina ; pharyngitis ; influenza ; rheumatism ; abscess ; 
traumatism; glandular fever; foreign bodies {e.g., 
calculi) ; new growths {e.g., fibrous polypus, hydatid 
cyst). 

The seat of a deposit, in follicular tonsillitis (small isolated 
w^hite pellicles which coalesce) ; in parenchymatous 
tonsillitis (at first white, later yellowish green, resem- 
bling "point of abscess") ; in tonsillitis herpetiformis 
(vesicular deposit, ending into ulcer) ; in necrotic ton- 
sillitis (yellowish-green patch) ; in influenza and 
pharyngitis (superficial exudation) ; in scarlatina and 
diphtheria (large pseudomembrane) ; in stomatitis 
mycotica (flour-like deposit). 

In doubtful cases it is imperative to examine a smear of the 
tonsillar deposit microscopically or bacteriologically. 

THE NECK. 

The lymphatic glands are — 

Enlarged, in all forms of angina, especially that due to 
diphtheria or scarlet fever; in afi:'ections of the mouth 
{e.g., stomatitis, gingivitis) ; in parotitis ; mastoiditis ; 
glandular fever ; pseudoleukemia ; scrofulosis (tuber- 
culosis) ; eczema capitis; local infections. 
The thyroid gland is — 

Enlarged, in goiter ; exophthalmic goiter ; endemic goitrous 



THE THORAX AND ITS CONTENTS. 17 

cretinism ; thyroiditis ; temporarily before menstrua- 
tion. 
Atrophied or absent, in sporadic cretinism. 

Tumefactions (other than those of the glands of the neck) — 
Hematoma of the sternocleidomastoid, in the center or 

at sternal insertion of the sternomastoid muscle. 
Hygroma cysticum, between lower jaw and clavicle, attains 

enormous size. 
Fistula coli congenita, at sternoclavicular articulation. 

Pulsation of the — 

Arteries, in aortic regurgitation ; hyperpyrexia, etc. 

Veins, in tricuspid insufficiency. 
Stiffness of neck — See ''Attitude of Head," page 5. 

THE THORAX AND ITS CONTENTS. 
AUSCULTATION AND PERCUSSION. 

Auscultation is best performed by means of a small bi-aural 
speculum, as with this instrument every inch of the infantile 
thorax can be thoroughly examined and small circumscribed 
lesions readily detected. 

Normally the respiratory sound is puerile (rough vesicular) 
in infancy or early childhood; and vesicular in older children. 

In auscultating the infantile lungs we should remember the 
following peculiarities: 1. During quiet respiration the in- 
spiratory sound is fairly audible, while the expiratory sound 
is but slightly so, — hence to obtain more distinct physical 
signs it is of advantage to disturb the infant, or to make it cry. 

2. Owing to the larger diameter of the right bronchus, the 
respiratory sounds are louder on the right side than on the left. 

3. Pure bronchial breathing is often normally heard over the 
interscapular regions, especially to the right of the spinal 
column. 4. Adventitious sounds originating in the naso- 
pharynx and larynx are frequently transmitted to the chest 
and may be misinterpreted as signs of pulmonary disease. 

The normal pulmonary percussion note is clear, loud, and 
somewhat tympanitic. It is somewhat metallic, when the 
child cries ; cracked-pot-like, over the right subclavicular 
region ; somewhat dull over the areas overlapping the liver, 
heart and spleen. 

2 



18 



EXAMINATION OF THE PATIENT. 



Percussion of the infantile lungs should be practised while 
the patient is held in a sitting posture, perfectly still and as 
erect as possible. It should be performed gently, preferably 
during the height of inspiration and expiration. Every portion 
of the lung should be carefully gone over, paying especial 
attention to the sub- and supra-clavicular spaces, which are not 




Fig. 5. — The Thoracic and Abdominal Regions. 1. Hypo- 
chondriac. 2. Lumbar. 3. Inguinal. (Sheffield.) 

rarel}^ the seat of consolidation, and the area corresponding to 
the tracheal bifurcation, which is often the seat of tuberculiza- 
tion of the bronchial glands. The physical signs obtained on 
percussion are not always conclusive, if percussion is per- 
formed too forcibly (may give rise to covibration of the more 
distant parts) ; if the child cries (during the act of crying com- 
pression of the lung by ascension of the diaphragm produces 
artificial dulness) ; if the position of the child is faulty (e.g., 
lying on the abdomen pushes the diaphragm upward and com- 
presses the lungs) ; or if the thorax is bent sharply forward. 



AUSCULTATION AND PERCUSSION. 19 

In auscultating the heart we should bear in mind the fol- 
lowing: 1. Accentuation of the first sound is heard equally as 
well at the arterial and venous orifices. 2. Accentuation of 
the second sound is ordinarily not heard imtil about the age of 
puberty. 3. Both heart sounds are louder in children than in 
adults and are more widely transmitted. 4. Reduplication of 
the heart sounds is not uncommon, and generally the result of 




Fig. 6. — The Regions of the Back. A. Suprascapular or 
supraspinatus. B. Scapular. C. Interscapular. D. Infrascap- 
ular or lower dorsal. E. Lumbar. F. Sacral. (Sheffield.) 

excitement. 5. In infants hemic murmurs are rare. 6. The 
heart-beat, as to frequency and rhythm, is apt to undergo great 
variations on slightest provocation. 

Percussion of the child's heart should be performed very 
gently while the patient sits quietly and bent slightly forward. 
The data obtained on percussion while the child cries, holds 
its breath, etc., are not wholly to be depended upon, since dur- 



20 EXAMINATION OF THE PATIENT. 

ing bodily unrest the heart is very apt to change its relation to 
the chest wall. The same holds true in the event of the heart 
being overlapped by emphysematous lungs ; if the heart is left 
bare by atrophy of the adjacent lung portions or by retraction 
of the heart or lungs by pleuritic or pericardial adhesions. 

THE THORAX. 

The normal infantile thorax is round and somewhat cylin- 
drical, its sagittal and transverse diameters being nearly equal. 
As the child grows older, the chest assumes a more conical 
shape, until at puberty it resembles that of the adult. The 
chest walls of the child are thin, elastic and yielding, owing to 
incomplete development of the muscular and bony structures. 
The ribs of the infant are nearly horizontal. 
The measurements of the thorax are — 

In the newly-born infant, about 14 inches. 

At one year, 17 inches. 

At three years, 20 inches. 

At six years, 23 inches. 

At twelve years, 26 inches. 

At the end of the fifteenth year, the measurement of the 
circumference of the chest is about half of that of the 
body length. 

Up to about eighteen months the circumference of the chest 
nearly equals that of the head. If from the end of the second 
year on the circumference of the head exceeds that of the 
chest, there is a strong suspicion of hydrocephalus, marked 
rachitis, contraction of the chest through pulmonary disease or 
imperfect development (adenoids). On the other hand, if the 
chest measurement in early childhood greatl}^ exceeds that of 
the head, it is indicative either of an abnormality of the chest, 
e.g., distension by fluids, or of congenital maldevelopment of 
the head, e.g., microcephalus, infantilism. 
Abnormal shape of chest — 

Barrel-shape (deep, short and broad), in emphysema, and 
the lung afifections that precede it, e.g., asthma, per- 
tussis ; protracted laryngeal stenosis. 

Flask-shape (flat, narrow and long), in phthisis pulmonum ; 
nasopharyngeal stenosis, especially adenoids. 

Funnel-shape (depression of lower portion of sternum), in 
rachitis; Barlow's disease; also congenital. 



THE LUNGS. 21 

Pigeon-breast-shape (protrusion of median portion of ster- 
num), in rachitis; congenital heart disease. 

Unilateral bulging, in pneumothorax ; pleurisy or pericar- 
ditis with effusion; tumor; scoliosis (opposite side). 

Unilateral flattening, in pleuritis retrahens (after absorp- 
tion of fluid) ; pulmonary contraction, e.g., tuberculosis ; 
after pyothorax operation ; scoliosis. 
Tumefactions — 

Costal, nodular, in rachitis (rachitic rosary) ; tuberculous 
and syphilitic processes; multiple exostoses. 

Intercostal, doughy, in suppuration of the bronchial glands ; 
empyema necessitatis ; lung hernia. 

Alammar}^, in mastitis ; cold abscess ; as a partial manifes- 
tation of parotitis ; new growths. 
Abnormal shape of scapulae — 

Prominent, uni- or bi-laterally, "angel wing" deformity, in 
congenital malformation ; in emaciation. Unilaterally, 
in scoliosis ; paralysis • of the scapular muscles, e.g., 
after local trauma ; poliomyelitis ; progressive atrophy. 

Sunken, in scoliosis; after empyema operation. 
Activity of the thorax in breathing is — 

Increased, bilaterally, in asthma ; laryngeal obstruction. 
Unilaterally, on the sound side, in pleurisy with 
effusion; pneumothorax; fixed deformities. 

Diminished, bilaterally, in emphysema ; hydrothorax ; 
diffuse tuberculization; paralytic conditions of the 
chest wall ; sclerema ; collapse. Unilaterally, in pleii- 
risy with eft'usion; pneumothorax; pleurodynia; pleu- 
ropneumonia with "stitch", pain. 
Pain on pressure — 

Superficial, in rheumatism of the chest muscles; intercostal 
neuralgia ; affections of the ribs (caries, periostitis, 
fracture, etc.) ; localized abscesses (empyema necessi- 
tatis) ; and tumefactions {e.g., mastitis). 

Deep, in pleurisy; pneumonia; phthisis pulmonalis. 

THE LUNGS.i 

The lungs are normally fully distended with air within the 
first few hours of life. In the premature or delicate infant full 



1 See "Auscultation and Percussion," page 17. 



22 



EXAMINATION OF THE PATIENT. 



lung inflation may not occur until several weeks after birth. 
The lower lobes particularly may remain in a state of atelec- 
tasis. 

The normal boundaries of the lungs differ somewhat with 
the age of the child. On both sides they project with their 
summits into the supraclavicular fossae. From here they 
descend in the following manner : — 

The right lung lies — 

In the sternal line at a point corresponding to the fifth 
(upper border) rib. 



STERINAL LINE 
PARASTERNAL LINE 
:^AMMARY LINE 







■J ; 



Fig. 7. — Diagnostic Lines of the Thorax. {Sheffield.) 



In the parasternal line at a point corresponding to the fifth 

(lower border) rib. 
in the mammary line at a point corresponding to the sixth 

rib. 
In the axillary line at a point corresponding to the seventh 

rib. 
In the scapular line at a point corresponding to the tenth 

rib. 

The left lung lies — 

In the sternal line at a point corresponding to the fourth 
rib. 



THE LUNGS. 



23 



In the parasternal line at a point corresponding to the 

fourth rib. 
In the mammary line at a point corresponding to the sixth 

rib. 
In the axillary line at a point corresponding to the seventh 

or eighth rib. 
In the scapular line at a point corresponding to the tenth 

rib. 
Posteriorly the base of the left lung is slightly lower than 

that of the right lung. 

Number of respirations per minute — 
In the newly born infant from 35 to 40. 
At the end of first year, 30. 




Fig. 8. — Anterior Boundaries of the Lungs. (Sheffield.) 

At the end of second year, 25. 

At six years, 22. 

At twelve years, 20. 

Character of respiration — 

Abdominal,, in children under four years of age. 

Costo-abdominal, in children (male and female) up to ten 
years ; in the male, in older ones. 

Thoracic, in girls over ten years old. 

Regularity of respiratory rhythm is usually not fully estab- 
lished before the age of two years. 

Abnormalities of respiration — 

Increased frequency, in respiratory and circulatory diseases 
(see "dyspnea") ; pyrexia; emotional excitement; com- 
pression of the lungs by an accumulation of gas, fluids, 
or solid masses. 



24 EXAMINATION OF THE PATIENT. 

Diminished frequency, in grave central disease ; extreme 
weakness; poisoning from belladonna, opium, etc. 

Costal breathing in boys over ten years old, and increased 
costal breathing in girls, in inflammatory diseases of 
the abdominal and pleural cavities (by interference 
with the action of the diaphragm) e.g., peritonitis, 
pleuritis; in abdominal distension by gases, fluids, or 
solid masses ; in paralysis of the diaphragm, e.g., bulbar 
paralysis, polioencephalitis, neuritis (postdiphtheritic) 
of the phrenic nerve; in drug poisoning; in hysteria. 




9. — Posterior Boundaries of Lungs. (Sheffield.) 



Purely abdominal breathing, especially in girls over ten 
years old, in emphysema ; scleroderma ; paralysis of 
respiratory muscles, e.g., bulbar paralysis. 

Irregular breathing, in conditions associated with ''diflicult 
breathing" ; in cerebrospinal affections ; in atelectasis ; 
painful diseases of the respiratory muscles ; in hysteria. 

Stertorous breathing, in nasopharyngeal obstruction, e.g., 
retropharyngeal abscess, adenoids; in uremic or apo- 
plectic coma. 

Cheyne-Stokes' breathing, occasionally in infants during- 
sleep ; in heart failure from divers causes ; in menin- 
gitis, especially the tuberculous variety; in meningeal 
hemorrhage, tumors or abscess exerting pressure upon 
the brain; in drug poisoning, e.g., opium; in death- 
agony. 



THE LUNGS. 25 

Difficult or labored breathing (dyspnea), in laryngeal, 
tracheal or bronchial obstruction from divers causes, 
e.g., croup, diphtheria, large thymus, asthma, etc. ; in 
affections associated with diminution of the usual pul- 
monary breathing area, such as active or passive con- 
gestion, compression or displacement by neoplasms, 
e.g., pneumonia, pleurisy or pericarditis with effusion, 
deformities of the thorax, advanced pulmonary tuber- 
culosis ; in grave circulatory disturbance inducing 
deficient oxygenation of the blood or obstruction to 
pulmonary circulation, e.g., blood, or heart diseases 
(''cardiac asthma") ; in conditions giving rise to "irreg- 
ular breathing" {q.v.) ''stertorous breathing" (q.v.)y 
and "Cheyne-Stokes' breathing"; in neuroses, e.g., hys- 
teria, neurasthenia — asthma hystericum. 

Respiratory sounds — 

Vesicular, exaggerated, in bronchial inflammation ; atelec- 
tasis. 
Weak, in thickened pleura ; moderate pleuritic 

effusion ; emphysema. 
Absent, in extensive pleuritic effusions. 
Bronchial, over the seat of the lesion, in pneumonia; tuber- 
culization. 
Above the seat of lesion, in compression of the lung 
by tumors in the chest cavity or by pleuritic 
exudates. 
Amphoric, in smooth-walled cavities ; open pneumothorax. 

Secretory sounds — 

Dry, sibilant and sonorous rhonchi, in bronchitis ; asthma 
(wheezing and whistling). 

Dry, crackling, in incipient phthisis (apex) ; beginning of 
second stage of pneumonia. 

Moist, large and medium-sized rales, in bronchitis (larger 
bronchial tubes) with abundant secretion; in cavities. 

Moist, small rales, in capillary bronchitis. 

Moist, crepitant (fine) rales, in croupous pneumonia (crepi- 
tatio indux or redux) ; catarrhal pneumonia; capillary 
bronchitis (in conjunction with coarse rales) ; tuber- 
culization ; pulmonary edema (in conjunction with 
larger moist rales). 



26 EXAMINATION OF THE PATIENT. 

Metallic tinkling, in pneumothorax. 

Metallic splashing or gurgling, in sero- or pyo-pneumo- 
thorax. 

Friction sound, in pleuritis sicca; pleuropneumonia; mil- 
iary tuberculosis. It is not altered by coughing, as is. 
the case with rales. 

Vocal resonance^ — 

Diminished, in bronchitis with free secretion; pleurisy with 
effusion; obstruction of bronchial tube; emphysema; 
pneumothorax. 

Increased, in tuberculization; pneumonia (over-consolida- 
tion). 

Bronchophony (concentration of voice near the ear), in 
tuberculization; pneumonic consolidation; compressed 
lung above pleuritic effusion ; bronchial dilatation. 

Exaggerated bronchial whisper; the same as for broncho- 
phony (q.v.). 

Pectoriloquy (complete transmission of sound), the same 
as for bronchophony (q.v.). 

Amphoric voice ("the echo"), in large cavity; pneumo- 
thorax. 

Egophony, bleating (goat-like resonance of voice), in 
pleurisy with effusion (near upper boundary of dul- 
ness) ; pleuropneumonia ; hydrothorax. 
Abnormal percussion-resonance — 

Dull or diminished resonance, in pneumonia; tubercle; neo- 
plasms; pulmonary gangrene; pulmonary abscess with 
thick masses; pleuritic thickening; atelectasis. 

Flat or absence of resonance, in pleurisy with effusion; 
hydrothorax; hemothorax. Resonance may alter with 
change of patient's position. Also in last stage of 
pneumonia with extensive consolidation. 

Tympanitic, or drum-like, resonance, in tuberculosis (cavi- 
ties) ; open pneumothorax; lung atrophy; above peri- 
cardial or pleuritic exudations or near neoplasms — the 
result of increased air pressure; pulmonary edema; 
moderate emphysema. 



1 Vocal resonance elicited on auscultation corresponds to vocal 
fremitus as obtained by palpation. Fremitus is increased in consoli- 
dation and diminished in effusions. 



COUGH. 27 

xA.mphoric, metallic, or concentrated tympanitic sound, in 
large tuberculous cavity with solid and tense walls 
lying close to the chest wall; occasionally heard in 
healthy child during crying. 

Cracked-pot-resonance, in pulmonary cavity communicating 
with the bronchial tubes — usually in tuberculosis ; may 
be elicited also in healthy child during talking or 
singing. 

Band-box-note (abnormally loud and deep), in pronounced 
emphysema; pneumothorax with strong tension of the 
chest wall. 

COUGH. 

It is essentially a reflex act arising from direct or indirect 
irritation of the respiratory center. In a measure it can be 
voluntarily produced or suppressed. The ability to cough is 
lost in paralysis of the crico-arytenoid or the respiratory mus- 
cles, hence cessation of coughing — with plenty of mucus in the 
bronchial tubes — particularly in pulmonary disease^ is con- 
sidered a bad omen. The nature of the cough may often be 
decided upon from its character. 
The cough is usually — 

Short and somewhat hoarse, in nasopharyngeal catarrh, 
adenoids. 

Loud and barking, in laryngitis and spasmodic croup. 

Dull, barking and somewhat moist, in ulceration of larynx 
(diphtheria, syphilis, etc.). 

Dry, tight and whistling, in early bronchitis. 

Soft, deep, and loose, in advanced bronchitis. 

Paroxysmal and whooping, in pertussis and other spas- 
modic affections. 

Hemming, in incipient phthisis and in nervousness. 

Short, sharp and painful, in pneumonia, pleurisy, and car- 
diac disease. 

Deep and distressing, in chronic phthisis, asthma, emphy- 
sema, etc. 

Too much reliance should not be placed upon the character 
of the cough, as it is very apt to vary with the duration of the 
cough, medication and complications. By far more reliable 
information may be obtained from a careful examination of 
the expectoration. 



28 EXAMINATION OF THE PATIENT. 

SPUTUM, EXPECTORATION. 

In cases where the children cannot or will not expectorate, 
the sputum may be obtained by introducing into the throat a 
sterile cotton swab or fenestrated stomach-tube — both of 
which usually receive enough of sputum during the act of 
coughing as to suffice for ordinary examination. 
The expectoration is — 

Mucous, frothy, grayish-white, in acute catarrh of the air 
passages. 

Mucopurulent, tenacious, yellowish-gray, in chronic tra- 
cheobronchial catarrh; in pertussis (voluminous, often 
mixed with vomitus) ; in asthma (Curschmann's 
spirals, Charcot crystals) ; in bronchiectasis (periodic 
"mouthful expectoration," separable into a purulent 
and mucoserous layer). 

Purulent, fetid, dirty grayish-green, in fetid or putrid bron- 
chitis (separable in three layers, suspended in the 
lowest, purulent, layer are Dittrich's plugs ) ; in pul- 
monary abscess (separable in two distinct layers, con- 
taining a great number of micrococci, elastic fibers, fat- 
crystals, etc.) ; in pulmonary gangrene (same as putrid 
bronchitis, plus tissue-fragments). 

Serous, prune-juice-like, and profuse, in pulmonary edema. 

Bloody, in nasopharyngeal catarrh with violent paroxysms 
of coughing (occasional streaks of blood) ; in foreign 
bodies in the air-passages (bright red mixed with 
frothy mucus) ; in pneumonia (uniformly stained, 
"rusty" sputum to dark "prune-juice" color with pneu- 
mococci) ; in heart disease, with edema (the same as in 
pulmonary edema from other causes; besides "heart- 
cells");, in tuberculous lesions of the air-passages 
(either large hemorrhage, "'hemoptysis," or blood 
stained "nummular" and heavy sputum, containing 
tubercle-bacilli) ; in neoplasms ("red-currant"-like spu- 
tum, with characteristic histologic structures) ; in 
vicarious menstruation ; hemorrhagic diathesis, and 
hysteria. See "Hematemesis" and "Epistaxis." 

The expectoration contains numerous micro-organisms and 
occasionally bile (in icterus), hydatid booklets, distomum pul- 
monale, and cercomonas. 



THE HEART. 



29 



THE HEART.i 

The heart is comparatively larger in infanc}' than in later 
life. It is relatively largest at birth, and smallest at about the 
age of seven years. At birth the walls of both ventricles are 
nearly of eqnal thickness, but as the infant grows older the 
left ventricle rapidly gains in thickness, so that by the end of 
the second year it is almost twice as thick as the right 
ventricle. 




Fig. 10. — Skiagram of Xormal Heart of a Child 8 Years Old. 



Corresponding to the relatively larger size and more trans- 
verse position of the heart of the young child, its boundaries 
are greatly at variance with those of the heart of the adult. 
The boundaries of the normal heart — 
The apex-beat is situated — 

To the left of the mammary line, in the fourth inter- 
costal space up to the fourth year of age. 
At the mammary line, at or slightly below the hfth rib 
up to the eighth year. 



iSt 



Auscultation and Percussion," page 17 



30 



EXAMINATION OF THE PATIENT. 



Slightly to the right of the mammary line, in the fifth 
intercostal space up to the twelfth year. 

Between the mammary and parasternal lines, i.e., the 
same as in the adult, in children over twelve years. 
The relative '' heart-dullness'' in infants is bounded as fol- 
lows : — 

Above, by a line corresponding to the lower border of 
the second rib. 




Fig. 11. — Topography of the Heart. (Sheffield.) 

On the left side, by a line parallel and slightly to the 

left of the left mammary line. 
On the right side, by the right parasternal line. 
Below, by a somewhat semicircular line along the 

fifth rib. 

As the child grows older and the heart assumes 

a more oblique and lower position, the boundaries 

of the relative heart dullness gradually fall in line 

with those of the adult. 



THE HEART. 31 

The absolute "heart-dullness'' in infants is bounded as fol- 
lows : — 

Above, by the upper border of the fourth rib. 

On the left side, by the left mammary line (slightly to 
the right of it). 

On the right side, by the left sternal line. 

Below, by a line corresponding to the upper border of 
the fifth rib. 

These boundaries, like those of the relative heart 
dullness, change gradually with the advance of the 
child's age, so that in children over twelve years 
old the upper boundary is formed by the fourth 
rib, the lower by a line drawn parallel to and be- 
tween the fifth and sixth ribs, on the right side by 
the sternal line, and on the left by a line midway 
between the parasternal and mammary lines. 



PARASTERNAL 
LINE 




Fig. 14. — Up to 12 years. 



The Relative and Absolute Heart Dullness at Different Ages. 
{Sheffield.) 



32 EXAMINATION OF THE PATIENT. 

The normal pulse-rate (most reliable when patient is asleep), 
is — 

In the newly-born infant from 120 to 150 per minute. 

At one year old 100 to 120 per minute. 

At four years 90 to 100 per minute. 

At eight years 80 to 90 per minute. 

At twelve years 75 to 80 per minute. 

Normal pulse-respiration ratio is approximately 1:4. A ratio 
of 1:3 or less is a certain indication of pulmonary disease, 
especially pneumonia. 




Fig. 15. — Location of Heart-apex at Different Ages. (Sheffield.) 

Apex-beat — 

Displaced — 

Outward, to the left, in hypertrophy of the right 
ventricle; dilatation of the right ventricle; right-sided 
pleurisy with effusion ; right-sided pneumothorax ; ab- 
dominal distention, pushing the diaphragm upward 
and the heart to the left. 

Outward and downward, in hypertrophy of the left 
ventricle; dilatation of the left ventricle; pericardial 
effusion ; congenital or acquired (by pressure from 
above, e.g., tumor or abscess) dislocation of the heart. 

Inward, to the right, in left-sided pleuritic effusion ; 
pronounced left-sided deformity of the thorax ; persist- 



THE HEART. 33 

ence of the embryonic position or situs inversus (up to 
dextrocardia). 

Effaced {i.e., apex-beat is invisible and barely palpable), in 
obesity ; pericardial eft'usion ; heart-failure ; emphy- 
sema ; edema cutis ; tumors. 

Diffuse, and weak in irregularity of the heart associated 
with grave heart disease. 

Diffuse and strong, in cardiac hypertrophy; hyperpyrexia; 
overstimulation; excitement. The cardiac impulse 
may only appear strong when the chest wall is very 
thin. 

Heart-sounds — 

Accentuation of — 

Systolic mitral, in excitement; fatigue; fever; hyper- 
trophy of left ventricle. 
Diastolic pulmonic, in hypertrophy of right ventricle. 
Diastolic aortic, in hypertrophy of left ventricle. 
Weakening of — 

Systolic mitral, in dilatation of the left ventricle ; loss 

of compensation. 
Diastolic pulmonic, in dilatation of the right ventricle 
(e.g., relative tricuspid insufficiency) ; stenosis of 
pulmonary artery. 
Diastolic aortic, in aortic stenosis. 
Division (double ) of diastolic at apex, in mitral stenosis ; 

adhesive pericarditis. 
Gallop rhythm, in heart-failure (e.g., incipient diphtheritic 

paralysis). 
Metallic ringing, in pneumopericardium; pneumothorax; 

large pulmonary cavity; intense meteorism. 
Murmurs — 

Systolic, loudest at apex and transmitted to axilla and 

angle of left scapula, in mitral regurgitation. 
Systolic, loudest at base (midsternum) and trans- 
mitted to the arteries upward and sometimes over 
the whole sternum, in aortic obstruction. 
S3^stolic, at base, but not transmitted upward, in pul- 
monic obstruction. 
Systolic, loudest at ensiform cartilage, in tricuspid 



34 



EXAMINATION OF THE PATIENT. 



Diastolic, loudest at base, and transmitted to apex and 

ensiform cartilage, in aortic regurgitation. 
Diastolic or presystolic, loudest at apex, in mitral 

obstruction. 
To-and-fro friction, superficial, limited to precordium, 

not influenced by respiration (as in pleuritis sicca), 

in fibrinous pericarditis. 




Fig. 16. — Topography of Cardiac Valves. Points of 
Transmission of Heart-murmurs. A. O., Aortic Obstruction. 
P. O. and R., Pulmonic Obstruction and Regurgitation. A. R., 
Aortic Regurgitation. T. O. and R., Tricuspid Obstruction and 
Regurgitation. M. O., Mitral Obstruction. M. R., Mitral Re- 
gurgitation. (Sheffield.) 

Areas of heart-dullness — 

Enlarged — 

To the left, in hypertrophy or dilatation of the left 

ventricle. 
To the right, in hypertrophy or dilatation of the right 

ventricle. 



THE PULSE. 35 

Bilaterally, in pericardial effusion. The area of dull- 
ness is larger in sitting than in recumbent posture ; 
it is often triangular, wider below than above. 

Reduced — 

In pulmonary emphysema ; pneumopericardium. 

Displaced — 

In congenital malpositions, e.g., dextrocardia, nieso- 

cardia, diaphragmatic hernia. 
In acquired affections, such as pneumothorax ; pleurisy 
with effusion ; neoplasms ; pleuritic retraction ; atro- 
phy of the lungs. 
The pulse — 

Frequent, in fright; excitement; fear; febrile diseases (ex- 
cept uncomplicated typhoid or meningitis) ; valvular 
heart diseases (except aortic stenosis) ; anemias, espe- 
cially on slight exertion ; tachycardia ; exophthalmic 
goiter; convalescence from acute affections; paralysis 
of the heart (central or peripheral paralysis of pneu- 
mogastric nerve) ; heart-failure {e.g., collapse in febrile 
diseases). 

Slow, in uncomplicated typhoid fever or meningitis ; after 
crises {e.g., pneumonia) ; acute nephritis ; catarrhal 
jaundice; intracranial pressure {e.g., hydrocephalus, 
hemorrhage, tumors) ; heart disease, such as aortic 
stenosis, myocarditis; bradycardia; profuse hemor- 
rhage; marked inanition {e.g., a pyloric stenosis); 
opium poisoning. 

Irregular, in last stages of valvular heart disease; myo- 
carditis ; profound anemia (on exertion) ; nervous 
palpitation; indigestion (flatulent colic). 
In the irregular pulse we distinguish the : — 

1. Intermittent pulse — 

Pulsus alternans (every second beat weak). 
Pulsus bigeminus (every third beat weak). 
Pulsus trigeminus (every fourth beat weak). 

2. Intercidens pulse (several regular beats suddenly 
followed by a small beat and pause), in heart 
weakness. 

3. Paradoxic pulse (the pulse grows smaller or ceases 

entirely on deep inspiration), in adhesive peri- 
carditis ; constriction of the air-passage ; mediastinal 
tumors. 



36 EXAMINATION OF THE PATIENT. 

4. Dicrotic or double pulse (in part explained by a loss 
in the muscular tone in the arteries, so that the 
arterial impulse is separated from that of the ven- 
tricles by a perceptible interval), in typhoid fever 
and less marked in other acute febrile diseases ; in 
chronic wasting diseases, especially tuberculosis; in 
anemias; after great loss of blood. 
Asymmetric (radial pulse), in congenital anatomical varia- 
tions of the artery on one side ; acquired narrowing, 
compression, or cicatricial contraction of the radial, 
brachial, axillary, subclavian or innominate artery; 
aneurism of the aforementioned arteries or of the 
aorta; in pneumothorax compressing the subclavian 
artery. 

THE ABDOMEN AND ITS CONTENTS. 

In order to save time, inspection and palpation of the 
abdomen may at once be supplemented by percussion, succus- 
sion, etc. To judge matters correctly we should bear in mind 
the normal relations of the abdominal parietes to the under- 
lying structures. 

The abdominal wall is moderately arched; readily com- 
pressible without undue resistance or pain; moves slightly 
upward and downward quite evenly and regularly with inspira- 
tion and expiration; and on percussion yields a loud, tym- 
panitic sound over all portions of the abdomen engaged by the 
intestines. 

The stomach at birth is nearly cylindrical and lies obliquely 
in the abdominal cavity. Gradually the fundus increases in 
size and the stomach assumes a transverse position in such a 
manner that five-sixths of its volume occupies the left half of 
the abdomen and one-sixth the right. The capacity of the 
stomach varies, of course, with the age and size of the child, 
as fully given when discussing "infant feeding" (page 77^. 

The infantile intestines, especially the small intestine, are 
relatively longer than those of the adult. At birth the small 
intestine is about nine feet long, the large intestine about 
eighteen inches, the sigmoid flexure forming about half of the 
colon. The capacity of the infantile intestines is relatively 
greater than in the adult, but their musculature is thinner and 
weaker, hence the tendency to constipation and colic. 



THE LIVER. 



37 



The liver of the newly born is relatively very large in size, 
much larger than in the adult, constituting in the former about 
one-eighteenth and in the latter about one thirty-sixth of the 
entire body weight. 

As the child grows older the size of the liver is greatly 
reduced, but owing to the sloping course of the lower ribs the 
liver appears considerably larger than it actually is. 




Fig. 17. — The Thoracic and Abdominal Regions. 1. Hypo- 
chondriac. 2. Lumbar, 3. Inguinal. {Sheffield.) 

Normal boundaries of the liver (as determined by percussion) : 
Upper border, midsternal line, base of ensiform cartilage. 
Mammary line, sixth rib. 
Midaxillary line, eighth rib. 
Scapular line^ tenth rib. 
Lower border, parasternal line, seventh rib. 

Mammary line, about half an inch below free border of 
ribs. 



38 EXAMINATION OF THE PATIENT. 

Midaxillary line, tenth rib. 

Scapular line, eleventh rib. 
Left border, joins lower absolute heart-dullness. 
Right border, joins the right kidney. 

Its position varies greatly with the ascent and descent of 
the diaphragm — rises with expiration and descends with deep 




Fig. 18. — Topography of the Liver and Spleen. (Sheffield.) 

inspiration. In the same manner it rises with intestinal 
meteorism, and descends with overdistention of the lungs 
through disease, e.g., emphysema or pneumothorax. 

The spleen lies in close contact with the diaphragm, and 
extends from the left midaxillary line to a point near the left 
border of the spinal column. Its upper border follows the 
ninth rib, its lower border the eleventh rib, for the most part 
bounding the left kidney. Normally the spleen cannot be out- 
lined by percussion, but during deep inspiration it can some- 



THE KIDNEYS. 39 

times be palpated at the free borders of the tenth and eleventh 
ribs. 

The kidneys are situated upon the right and left sides of the 
spinal column, and extend from the levels of the twelfth dorsal 
to the second lumbar A-ertebrse. The uppermost end of the 
right kidney (the suprarenal capsule) is slightly overlapped by 
the liver and that of the left kidney by the spleen. Normal 




Fig. 19. — Topography of Kidneys, Spleen, and Liver. S. 
Spleen. L. Liver. K. Kidneys. (Sheffield.) 

kidneys are occasionally palpable, but can never be outlined by 
percussion. 

The urinary bladder is situated underneath the symphysis 
pubis, but when fully distended rises above it, eliciting dull 
percussion resonance. 
Abnormal size and shape of abdomen — 

Large and uniform, in flatulence; acute and chronic gas- 
tro-enteritis ; acute peritonitis from various causes ; 
intestinal atony or paralysis; extensive ascites. 



40 EXAMINATION OF THE PATIENT. 

Large and irregular, in gastrointestinal disease (congenital 
megacolon, pyloric stenosis, intussusception, appen- 
dical tumor or abscess, fecal impaction, strangulation, 
helminthiasis, tuberculosis) ; in peritoneal or omental 
affections (chronic peritonitis, tuberculosis, sacculated 
abscess, sarcoma, cysts) ; in liver disease (congestion, 
abscess, syphilis, rachitis, fatty or amyloid degenera- 
tion, leukemia, pseudoleukemia, hypertrophic cirrhosis, 
neoplasms) ; in spleen affections (leukemia, pseudo- 
leukemia infantum, rickets, syphilis, typhoid, malaria, 
sepsis, neoplasms) ; in kidney disease (floating kidney, 
perinephritic abscess, neoplasms, hydronephrosis) ; also 
overdistention of the urinary bladder; large ovarian 
cysts ; local injuries of the abdominal wall. 

Retracted, in collapse especially from gastro-intestinal dis- 
ease; in inanition (pyloric or esophageal stenosis); in 
meningitis (''scaphoid abdomen") ; general cachexia 
and loss of fat and muscle. 

Increased, abdominal resistance — 

Local, in localized affections of the different abdominal 
organs (tumors, abscesses, foreign bodies, e.g., fecal 
impaction; helminthiasis). 

General, in hyperesthesia; rheumatism of abdominal mus- 
cles ; colic ; peritonitis from different causes ; appendi- 
citis; sclerema; scleredema; extensive dropsical effu- 
sion. 

Abdominal pain — 

In all conditions enumerated under ''abdominal resistance," 
except sclerema, scleredema, and dropsy. In pneu- 
monia, pleurisy — reflex; in cholelithiasis; gastralgia ; 
ulcer ; nephrolithiasis ; cystitis ; vesical calculi ; intes- 
tinal adhesions; ren mobilis ; uterine and ovarian dis- 
ease (in older girls) ; in hysteria. 

Visible intestinal peristalsis — 

Normal, in very thin and lax abdominal parietes, e.g., con- 
genital diastasis recti abdominis (see Fig. 37) ; infan- 
tile athrepsia; atrophy due to paralysis. 

Abnormal (increased or reversed), in pylorus stenosis; 
intestinal obstruction or constriction from various 
causes ; congenital dilatation of the colon. 



VOMITING. 41 

Palpable or visible herniae — 

In the linea alba (ventral; diastasis recti abdominis). 

At the umbilicus (congenital hernia of the cord — ectopia 

viscerum; simple umbilical hernia). 
In the lumbar triangles (lumbar hernia; lateral ventral 

hernia). 
In the inguinal regions (direct and oblique inguinal 

herniae). 
At the femoral fossa (femoral or crural hernia). 
Vomiting — 

Gastro-enteric (associated with nausea and effort ; followed 
by relief) ; in simple gastroenteric disturbances and 
intoxication; pyloric stenosis or spasm; intestinal 
obstruction from various causes ; appendicitis ; peri- 
tonitis ; the effect of emetics or poisonous drugs (taken 
by mouth). 
Cerebral (explosive; watery, recurrent without relief). 

Direct, in acute and chronic aiTections of the cerebro- 
spinal system ; shock ; psychic emotion. 
Reflex, in extracranial irritation of the cranial nerves, 
e.g., of the optic or oculomotor nerves in visual 
defects; of the auditory nerve, in otitides ; pneumo- 
gastric, in pulmonary and cardiac diseases. Also 
in toxemia, by bacterial or chemical products {e.g., 
sepsis, uremia, etc.). To the latter group belong 
also the so-called ''cyclic" vomiting and the vomit- 
ing accompanying migraine. 
Vomitus — 

Mucous, in chronic catarrh of the stomach; after swallow- 
ing large quantities of expectoration, in nasopharyn- 
geal and laryngeal inflammation or pertussis. 
Bilious (yellowish-green or green), in gastro-enteric dis- 
turbances after repeated vomiting ; in peritonitis ; intes- 
tinal obstruction; liver affections. 
Bloody (hematemesis), in hemophilia and melena neona- 
torum ; congenital obliteration of the bile-ducts ; cir- 
rhosis of the liver ; ulceration of the lining of alimen- 
tary tract, especially of the upper part (from corrosive 
poisons ; syphilis, etc) ; in vicarious menstruation. 
Purulent, in rupture into the stomach of large abscesses in 
the adjacent organs {e.g., empyema). 



42 EXAMINATION OF THE PATIENT. 

Fecal, in severe intestinal obstruction with reversed peris- 
talsis {e.g., intussusception). 
Parasitic, in helminthiasis; ankylostomum duodenale ; 
trichinae; echinococci. 
Diarrheal — One to two movements in twenty-four hours are 
looked upon as normal. But even double the number of 
evacuations is not necessarily a manifestation of a path- 
ologic condition unless the consistency, color and odor of 
the stools are materially altered. As on the first visit a 
specimen of the stool is not always obtainable, and if 
obtained not invariably of the same consistence as the pre- 
ceding movements, it is important to gather all the infor- 
mation possible as to the abnormality in question — number, 
time of occurrence, quantity and quality. 

1. Acute diarrhea occurs after the administration of cathar- 

tics or corrosives ; in indigestion ; stomatitis ; gastro- 
enterocolitis ; proctitis and dysentery (blood, mucus 
and often pus) ; acute peritonitis ; during the course of 
divers infectious diseases, especially cholera, typhoid, 
scarlatina, measles, influenza, sepsis, etc. 

2. Chronic diarrhea is observed in dyspepsia; chronic 

gastroenterocolitis ; chronic proctitis and dysentery 
(amebic) ; intestinal tuberculosis and other chronic 
wasting diseases (especially syphilis, leukemia, amy- 
loidosis) ; helminthiasis (especially in trichocephalus 
and ankylostomum — often mucosanguinolent stools) ; 
malaria (periodic) ; intestinal lithiasis (mucus, blood 
and sand), and in partial intestinal stenosis (band-like, 
flat, mixed with mucus). 
Constipation^ — In determining the clinical significance of con- 
stipation, inquiry should be made as regards the duration 
of the constipation, mode of feeding of the child, presence 
or absence of vomiting and tenesmus, and the color and 
consistency of the stools. 

1. Habitual constipation occurs in consequence of insuffi- 
cient (pyloric stenosis) or improper feeding (lack of 
fat, water, etc., excess of starches, etc.) ; intestinal 
atony (from a great number of causes, e.g., congenital 
or acquired muscular insufliciency — megacolon, or 



1 See "Infants' Stools," page 43. 

2 Ibid. I 



INFANTS' STOOLS. 48 

artificial distention), general debility, cretinism, etc.; 
partial intestinal obstruction {e.g., hernia, neoplasms) 
and abstinence owing to painful lesions in the rectum 
{e.g., hemorrhoids, fissures). 
2. Acute constipation, with persistent vomiting, pain, 
meteorism, etc. — in all forms of congenital intestinal 
atresia and acquired acute intestinal obstruction 
(intussusception, strangulation, fecal impaction, peri- 
tonitis, appendicitis, and volvulus). 

INFANTS' STOOLS. 

The character (consistency, color, reaction, odor, etc.) of 
infants' stools greatly depends upon the kind and quantity of 
food consumed. 
Normal stools are — 

Soft and pasty, golden yellow^, slightly acid and almost 

odorless, in breast-milk feeding. 
Soft — putty-like — whitish-yellow, slightly alkaline and 

slightly offensive in odor, in cows' milk feeding. 
Soft — salve-like — yellowish-brown or broWn, slightly alka- 
line or neutral, and malt-like in odor, in feeding with 
malted or farinaceous foods. 
Abnormal Stools — 
(a) Consistency — 

Thick and formed, in deficiency of fat supply; excess 

of starches; habitual constipation. 
Soft, smeary, like moistened shavings of soap, in fat 

indigestion. 
Soft or hard and mixed with tough white curds, in 

casein indigestion. 
Thin, watery, in catarrhal gastroenteritis ; typhoid 
fever; from the effects of hydragogue cathartics; 
rectal stricture {e.g., syphilitic). 
Serous, in severe gastroenterocolitis; cholera. 
Mucous, in obstinate constipation with tenesmus ; in 
disease of the large intestine (large quantity) ; in 
disease of small intestine (mixed with feces). 
Bloody, in rectal aft'ections {e.g., proctitis, hemorrhoids, 
fissure, polypus, prolapsus); dysentery; intussus- 
ception; hemorrhagic disease {e.g., melena, pur- 
pura, hemophilia, etc.) ; foreign body in rectum. 



44 EXAMINATION OF THE PATIENT. 

(b) Color— 

Yellowish-green, in gastrointestinal indigestion (espe- 
cially of casein). 

Green, in gastroenteritis; from the effects of calomel. 

Clay-color, in obstruction to the flow of bile. 

Black, in meconium; from the effects of iron, man- 
ganese and bismuth; also blood (coming from 
upper portion of the bowels). 

Red, from admixture of blood (from lower portion of 
bowels, especially rectum). 

(c) Reaction — 

Decidedly alkaline, in proteid indigestion. 
Moderately acid, in fat indigestion (from fatty acids) ; 
carbohydrate indigestion (acetic or lactic acid). 

(d) Odor- 
Foul, in proteid indigestion; fermentation. 
Rancid, in fat indigestion. 

Sour or pungent, in carbohydrate indigestion. 
The stools should be examined also for parasites (see 
''Intestinal Worms" page 222) and calculi. 

PRINCIPAL ABNORMALITIES OF URINE. 

In male infants the urine may be collected by placing the 
penis in a test-tube or the neck of small bottle fastened by 
means of strips of adhesive plaster; in female infants, by 
placing absorbent cotton in front of the vulva. Where these 
measures fail, catheterization should be resorted to. 

Traces of albumin and sugar; occasionally hyaline and 
granular casts ; a moderate amount of mucus, uric acid crystals 
and urea, are found in the urine of healthy infants a few weeks' 
old. 

The quantity of urine passed in twenty-four hours is larger 
in infants than in older children, but varies with the amount of 
liquid consumed. It is smaller in breast-fed than in bottle- 
fed babies. 
Polyuria (increased amount of urine) — 

Diabetes mellitus. 

Diabetes insipidus. 

Contracted kidney. 

Granular atrophy of the kidney. 



ABNORMALITIES OF URINE. 45 

Amyloid kidney. 

Convalescence after acute diseases (epicritic polyuria). 

Disease of the nervous system, functional and organic, as 

hysteria, neurasthenia, migraine, chorea, epilepsy, 

tabes, cerebrospinal meningitis, 
^ledicinal (acetates, salicylates, digitalis, calomel, etc.). 
Oliguria (decreased secretion of urine) — 
Febrile conditions. 
Profuse diarrhea. 
Circulatory disturbances. 
Acute nephritis. 

Some forms of chronic nephritis. 
Anuria (suppression of urine) — 
Uremia. 
Acute anemia. 

Catarrh of the stomach or intestines. 
Cholera. 
Dysentery. 
, Nervous manifestations. 
Lead colic. 
Poisoning with arsenic, corrosive sublimate, morphine, 

atropine, oxalic acid, etc. 
Glycosuria — 

Constant in diabetes mellitus. 
Transient glycosuria — 

Cholera. 

Typhoid fever. 

Intermittent fever, particularly during convalescence. 

Syphilis. 

Scarlatina. 

Measles. 

Diphtheria. 

Influenza. 

Gout. 

Disease of the lungs and liver. 

Disease of the brain, especially if involving the fourth 
ventricle. 

Cerebrospinal meningitis. 

Tetanus. 

Lesions afTecting the central and peripheral nervous 
svstem. 



46 EXAMINATION OF THE PATIENT. 

Poisoning with morphine, atropine, strychnine, oxalic 
acid, carbon monoxide, lead, chromates, chloroform, 
ether, etc. 
Transient alimentary glycosuria — 

Disorder of the stomach. 

Overingestion of starchy and saccharine foods. 

Cirrhosis of the liver. 

Mor1)us Basedowii. 

Disease of the heart. 

Phosphorus poisoning. 

Atrophy of the liver. 

Traumatic neuroses. 

Fatty degeneration of the liver. 

Psoriasis. 
Aceton — 

Diabetes mellitus, especially in advanced cases; diabetic 

coma. 
Fever. 
Carcinoma. 
Auto-intoxication. 
Psychoses. 

After chloroform narcosis. 
Diacetic acid — 

Diabetes mellitus, advanced cases. 
Auto-intoxication (diaceturia). 
Albuminuria — 

(a) Renal (nephritis, pyelitis, pyelonephritis, nephrolithiasis) 

and vesical (calculi, colicystitis). 

(b) Changes in the constitution of the blood: 
Ischemia. 

Anemia. 

Struma. 

General weakness. 

Efifect of certain poisons, as cantharides, mustard, oil 

of turpentine, carbolic acid, alcohol, lead, etc. 
Infectious fevers — micro-organisms in the blood. 
Febrile conditions. 

(c) Disturbance in the circulation: 
Acceleration of the arterial current. 
Slowing of the venous current. 
Prolonged muscular exercise. 



ABNORMALITIES OF URINE. 



47 



After cold baths. 

After epileptic fits. 

Compression of the thorax. 

Derangement of the cerebrospinal system. 

(d) Functional. 
Orthotic. 

(e) Digestive. 

Ingestion of excessive quantities of albumin {e.g., eggs, 
cheese, raw beef). 




Fig. 20. — Severe Acute (at first decidedly hemorrhagic) 
Nephritis, which Ended Fatally in Four Weeks. X 350. h. 
Hyaline cast, g. Granular cast, w. Waxy cast, e. Epithelial 
cast, ep, Free renal epithelia. Also two finely granular, uniformly 
fatty renal epithelia. {Lenhartz.) 



Casts- 
Hyaline (narrow and broad) : 

Acute and chronic nephritis. 
Granular (coarse and fine granules) : 

Chronic pathologic conditions of the kidney. 
Epithelial : 

Inflammation in the anatomical structure. 
Bloody: 

Hematuria. 

Acute diffuse nephritis. 

Acute renal congestion. 

Hemorrhagic infarction of the kidney. 



48 EXAMINATION OF THE PATIENT. 

Fatty : 

Fatty changes in the kidney, large white kidney. 
Waxy : 

Amyloid kidney and many forms of nephritis. 
Bacterial : 

Interstitial suppurative nephritis, ascending pyelo- 
nephritis. 
Purulent : 

Abscess of the kidney. 
Uric acid (pathologic when deposit occurs shortly after urine 
is voided) — 
Acute fevers. 
Inflammation. 

Increased tissue metabolism. 
Defective physiologic action of the liver. 
Sedentary habits of life. 
Early stages of interstitial nephritis. 
Convalescence from scarlatina. 
Hematuria (blood) — 

(a) Renal: Cystic disease of the kidney. 
Bright's disease. Abscess. 

Amyloid disease. Renal embolism. 

Malignant growths. Hydatids. 

Tuberculosis. Acute febrile processes. 

Renal calculi. Purpura hemorrhagica. 

Traumatism involving the kidney. 
Medicinal, as turpentine, cantharides, arsenic, etc. 

(b) Vesical: Cystitis. 

Stone in the bladder. Neoplasms of the bladder. 

(c) Urethral: Neoplasms. 
Acute gonorrhea. Traumatism. 

Pyuria (pus) — 

(a) Renal: Cancer. 
Pyelonephritis. Tuberculosis. 
Pyelitis. Nephritic abscess. 

(b) Vesical: 

Cystitis. Ulceration. 

Vesical stone. Tuberculosis. 

(c) Urethral : Rupture of abscess in urinary passages. 
Gonorrhea. Urethritis. 



THE GENITALIA. 49 

Peptonuria (pepton) — 

Croupous pneumonia. Typhoid fever. 

Bronchopneumonia. Scarlet fever. 

Empyema. Malaria. 

Phthisis pulmonum. Erysipelas. 

Epidemic cerebrospinal meningitis. 

Purpura hemorrhagica — diverse forms. 

Scurvy. 
Bacteriuria (pathogenic) — 

Gonococcus. Colon bacillus. 

Tubercle bacillus. • Strepto- or staphylo-cocci. 

Parasituria — 

Distomum haematobium. Filaria. 

Hooklets of echinococcus. 

THE GENITALIA. 

In the male child we should look for abnormalities of the 
penis (malformations, adhesions of the prepuce, phimosis, 
overstretched prepuce, — masturbation, — faulty location of the 
urethral orifice, urethral discharge), scrotum and its contents 
(tumefactions, undescended testicles). 
Scrotal tumefactions — 

Communicating with abdominal cavity, in hernia ; hydro- 
cele ; and, higher up in the inguinal canal, partly 
descended testicle. 
Non-communicating with abdominal wall, in orchitis (not 
rarely with parotitis); epididymitis; syphilis, tuber- 
culosis, cysts, and malignant growths of testicle. 
Dropsical effusions, of renal or cardiac origin or edema 

from circulatory disturbance in the spermatic cord. 
Local scrotal inflammation, in abscess ; erysipelas ; gan- 
grene; sebaceous cysts; traumatism. 
In the female we should note the presence of labial hernia 
or hematoma, vaginal discharges or deposits (in diphtheria, 
noma); enlarged clitoris or preputial adhesions; atresia 
vaginae; abnormalities of the hymen (imperforate). 
Vulvovaginal discharge — 

jMucous, white, in simple catarrhal vulvovaginitis (from 

lack of cleanliness; irritating urine). 
Purulent, yellow or yellowish-green, in gonorrheal vulvo- 



50 EXAMINATION OF THE PATIENT. 

vaginitis or infection by other micro-organisms {e.g., 
streptococcus in exanthematous diseases). 
Hemorrhagic, in hemorrhagic diathesis (in the newly-born 
and in older children) ; in vulvovaginitis with erosions 
of the mucous membrane (sometimes after severe local 
treatment) ; prolapse of the urethra; neoplasms; men- 
struatio prsecox, 

THE RECTUM. 

Abnormalities of the rectum can readily be detected by 
inspection (sometimes with the aid of proctoscope) and digital 
examination. We should look for condylomata, fistulas, 
hemorrhoids, poh^ps, prolapse, intussuscepted intestine, fis- 
sures, pinworms, foreign bodies and discharges. 
Rectal discharges — 

Mucous, mucopurulent, and slightly bloody, in simple proc- 
titis; rectal fissure or fistula; colitis. 
Purulent, in communicating ischiorectal abscess; gonor- 
rheal proctitis; impacted foreign body. 
Hemorrhagic, in hemorrhoids; polyps; dysentery; ulcera- 
tive proctitis (tuberculous, or otherwise) ; intussuscep- 
tion; prolapsus recti; hemorrhagic diathesis. 

THE VERTEBRAL COLUMN. 

The vertebral column of the infant under six months is 
quite straight, except for a slight dorsal curve. As the child 
grows older and attains the power of sitting, standing and 
walking, we soon find the dorsal region of the spinal column 
curved posteriorly and the cervical and lumbar regions ante- 
riorly — compensator}^ curvatures. At first these curves dis- 
appear in recumbent posture, but they become permanent at 
about the age of six. The normal spinal column is perfectly 
movable. 

In the physical examination of the spinal column we note 
the presence of: — 
Deformities (lordosis, kyphosis and scoliosis) — 

Congenital, in osteogenesis imperfecta, etc., cervical rib. 

Habitual, or postural from faulty posture ; the efifect of 
superencumbrance (carrying of heavy Aveights upon 
the back or shoulders). 



THE EXTREMITIES. 51 

Static, the result of oblique pelvis, e.g., congenital or 
acquired shortening- of one lower extremity in hip- 
joint disease. 

Tuberculous, in vertebral caries. 

Neuromuscular, in muscular insufficiency (to which be- 
longs also rachitic deformity of the spine j, or paralysis, 
e.g., poliomyelitis; pseudoparalysis. 
Clefts, usually congenital, e.g., spina bifida. 
Tumors — 

Congenital, in teratomas ; hernial protrusions. 

Acquired, in A^ertebral caries, osteoma. 
Stiffness (with or without pain) — 

Central, in meningitis; meningeal irritation {e.g., apex 
pneumonia; hydrocephaloid). 

Spinal, in disease of the spinal cord {e.g., spinal meningitis, 
myelitis) ; in trauma or disease of the A'ertebrse or artic- 
ulation {e.g., vertebral caries, spondylarthritis). Also 
cervical rib ; osteoma. 

Neuromuscular, in neuralgia ; myalgia ; myositis. 

For further information the reader is referred to "Attitude 
of the Head and Neck" and "Spondylitis." 

THE EXTREMITIES. 

The extremities should be examined Avith a great deal 
of care — inspected, measured, palpated, percussed — as their 
anomalies in form and disturbances in function, etc., furnish 
most instructive information not alone as to existence of local 
disease, but also of general systemic afitections, pre-eminently 
those of the nerve system. 
Shortness of — 

Single limbs, in paralytic, hysterical or traumatic {e.g., after 
fracture) contractures; hip-joint disease; congenital 
deformities. 
All extremities, in achondroplasia (as compared Avith the 
long trunk). 
Curvatures — 

Congenital, in diA'erse congenital malformations {e.g., osteo- 
genesis imperfecta; osteomalacia; achondroplasia). 
Acquired, after fractures ; in syphilis ; rachitis ; tuberculosis. 
Tumefactions — 

Diaphyseal, tuberculous and non-tuberculous in periostitis ; 



52 EXAMINATION OF THE PATIENT. 

osteitis ; osteomyelitis ; syphilis ; exostosis ; malignant 
growths ; after fracture. 

Epiphyseal, the same as in diaphyseal, also in rachitis ; Bar- 
low's disease ; arthritis deformans ; rheumatic affec- 
tions ; septic arthritides ; hemarthrosis (hemophilia, 
peliosis rheumatica) ; synovitis ; bursitis ; "intermittent 
hydrops." 
Muscular Weakness, "flaccidity" (with or without atrophy) : 

Without True Paralysis, in pseudoparalysis of syphilitic 
origin (upper extremities); Barlow's disease; osteo- 
myelitis; osteomalacia; polyarthritis and myositis; 
traumatism to the muscles or bones (dislocation or 
fracture) ; progressive muscular atrophies (muscular 
and neurospinal types) ; idiocy (especially amaurotic 
family idiocy) and cretinism; rachitis and muscular 
debility after prolonged sickness (in bed) ; hysteria. 

With Paresis or Paralysis, in poliomyelitis (early) ; mye- 
litis (the muscular involvement depending upon the 
seat of the lesion in the cord) Landry's paralysis ; 
spinal meningitis (chronic) ; polyneuritis (usually 
bilateral and symmetrical) from various causes; birth 
palsies. 
Muscular Contracture, "spasticity" (with or without atrophy) : 

Without True Paralysis, in trismus and tetanus trauma- 
ticus and neonatorum; meningismus; early stage of 
meningitis; tetany; pseudotetanus ; tetanism (q.v.); 
eclampsia infantilis; myotonia; catalepsy; hysteria 
trichinosis ; hydrocephaloid. 

With Paresis or Paralysis, in all forms of cerebral paralysis 
(cerebral hemorrhage, embolism, abscess, tumor, scle- 
rosis, tuberculosis, encephalitis, porencephalia, hydro- 
or micro-cephalus, etc.) ; myelitis (late stage) ; spastic 
spinal paralysis; Little's disease; amyotrophic lateral 
sclerosis. 
Spasmodic Movements (see also "Convulsions") : 

Intention tremor, in disseminated sclerosis; ataxia heredi- 
taria ; spastic spinal paralysis ; myotonia congenita. 

Irregular shaking, in cerebral hemorrhage ; tumor ; enceph- 
alitis ; hydrocephalus; all forms of meningitis; toxic 
neuritis, especially diphtheritic and uremic; hysteria; 
Jacksonian epilepsy; idiocy. 



THE EXTREMITIES. 53 

Fibrillary twitching, in progressive muscular atrophy ; 

acute febrile diseases ; neuroses ; strychnin poisoning. 

Athetoid movements, in chronic brain affections, especially 

of the internal capsule. 
Choreiform movements, in all forms of chorea ; spastic 
cerebral paralysis ; paramyoclonus multiplex ; hysteria ; 
tic. 
Paralysis — 
Unilateral. 

Upper and lower, in lesions of one cerebral hemisphere, 
e.g., cerebral hemorrhage, embolism, abscess, tumor, 
sclerosis, encephalitis, meningitis, depressed frac- 
ture, porencephalia, etc. ; poliomyelitis. 
Upper, in unilateral, cerebral lesion of the arm center, 
e.g., embolism, tubercle, etc. ; unilateral spinal lesion 
of the cervical region, e.g., incipient spondylitis, 
etc. ; traumatism to the brachial plexus, e.g., birth 
palsy ; poliomyelitis ; regressive stage after hemi- 
plegia. 
Lower, in unilateral cerebral lesion of the leg center 
(same as in upper) ; unilateral spinal lesion in the 
lumbar region ; trauma of the lumbar plexus ; polio- 
myelitis. 
Bilateral. 

Upper and lower, in bilateral lesions of the brain (cor- 
tex, pons, or medulla), e.g., intracranial hemorrhage, 
multiple growths, especially tuberculous and syph- 
ilitic, disseminated sclerosis, etc., spinal sclerosis ; 
spinal meningitis ; poliomyelitis ; Landry's paralysis 
(late) ; progressiA^e muscular atrophy (late) ; amyo- 
trophic lateral sclerosis (late) ; syringomyelia 
(late); multiple neuritis; amaurotic family idiocy 
(late). 
Upper, in double trauma of the brachial plexus or in- 
dividual cords, e.g., compression in instrumental 
delivery ; transverse cervical myelitis ; poliomye- 
litis ; Landry's paralysis (late) ; bilateral cerebral 
lesions of the arm centers; syringomyelia (early). 
Lower, in bilateral trauma of the lumbar plexus or its 
main branches ; transverse lumbar myelitis ; trans- 
verse dorsal myelitis (late) ; spastic spinal paralysis ; 



54 EXAMINATION OF THE PATIENT. 

hereditary ataxia (late) ; tabes dorsalis (late) ; poly- 
neuritis, especially diphtheritic (early) ; amyo- 
trophic lateral sclerosis (early) ; poliomyelitis ; bi- 
lateral cerebral lesions of the leg centers ; hydro- 
cephalus. 
Localized paralysis of principal muscles concerned in move- 
ments of the extremities and their nerve supply. 
Upper extremities. 

Trapezius (spinal accessory nerve) : sinking of 
shoulder downward and forward ; rotation of 
scapula outward and upward; elevation of 
shoulder imperfect. 
Serratus magnus (long thoracic nerve) : slight rota- 
tion of scapula; difficulty of raising arm above 
shoulder; deep furrow between scapula and 
vertebrae on moving arm upward. 
Pectorales (anterior thoracic nerves) : impaired 
abduction of upper arm ; placing of affected hand 
on healthy shoulder impossible. 
Teres major and s^ubscapular (subscapular nerves) : 

Loss of inward rotation of arm. 
Infraspinatus (suprascapular nerve) and teres 
minor (axillary nerve) : loss of outward rota- 
tion of arm. 
Latissimus dorsi (subscapular nerve) : impaired 
abduction of arm; inability to place hand on 
sacrum. 
Deltoid (circumflex nerve) : inability to elevate 

arm; atroph}^ 
Biceps and brachialis anticus (musculocutaneous) : 
inability to flex forearm, when in supination ; in- 
ability to supinate forearm, when flexed. 
Supinator longus and brevis (musculospiral nerve) : 
weakened flexion when forearm is half-pronated ; 
inability to supinate with the forearm extended 
and pronated. 
Triceps and the extensors (musculospiral nerve, 
''radial paralysis") : inability to extend fore- 
arm (in triceps paralysis) ; hand-drop in flexed 
position; flexion of fingers; impaired abduction 



THE EXTREMITIES. 55 

and adduction (paralysis of the extensors) ; im- 
paired sensation along radial side; atrophy. 

Flexor carpi ulnaris, profundus digitorum, minimi 
digiti, and inner head of brevis pollicis ; the 
interossei, lumbricalis, palmaris brevis (ulnar 
nerA'e, "ulnar paralysis") : claw-like deformity 
of hand. 

Pronator radii teres, pronator quadratus, palmaris 
longus ; flexors carpi radialis, sublimis digi- 
torum, profundus digitorum, and longus pollicis 
(median nerve, "median paralysis") : abolition 
of power of pronation ; inability to flex terminal 
phalanges and thumb; objects can be grasped 
with the last three fingers only ; trophic and sen- 
sory disturbance. 

See also "Birth-palsy." 
LoAver extremities. 

Gluteus maximus and minimus (gluteal nerve) : 
difficulty to abduct thigh; to walk up-hill; to 
rise from sitting posture ; impairment of circum- 
duction and iuAA'ard rotation, and Avalking; toes 
are turned iuAvard. 

Anterior muscles of thigh, except tensor A'aginae 
femoris (anterior crural nerA^e, "crural paral- 
ysis") : inability to flex thigh on trunk and to 
flex trunk Avhen in recumbent posture; to extend 
leg Avhen flexed; difiiculty to stand or Avalk, or 
to rise from kneeling posture. 

Obturator externus and the abductors (obturator 
nerA'e ) : impaired adduction and outAvard rota- 
tion of thigh ; inability to cross legs. 

Biceps, semimembranosus, semitendinosus, the flex- 
ors of knee (great sciatic nerA'e): inability to 
flex knee ; diflicult locomotion ; leg iuA'erted or 
CA'erted. 

Gastrocnemius, soleus, and plantaris — the extensors 
of the foot (internal popliteal nerA'e) : inability 
to extend (plantar flexion) of foot; to stand on 
tip-toe; difficulty in Avalking; foot CA'erted, ankle 
loAvered (talipes calcaneus). 



56 EXAMINATION OF THE PATIENT. 

Peroneus longus (musculocutaneous) : foot in- 
verted; plantar arch flattened (flat-foot). 
Tibialis anticus, and extensor longus digitorum — 
flexors of foot (anterior tibial nerve) : impaired 
flexion, abduction and adduction (talipes equi- 
nus). 
Peroneus brevis, and tibialis posticus (posterior 
tibial nerve) : inability to adduct or abduct foot 
without flexion or extension. Talipes valgus in 
tibial paralysis; talipes varus in peroneal paral- 
ysis. 
Peculiarities of gait — 

Dragging, in multiple sclerosis; spastic spinal paralysis; 
poliomyelitis involving both legs ; amyotrophic lateral 
sclerosis; hemiplegia, and cretinism. 
Straddling, in tabes dorsalis. 
Staggering, reeling, in multiple neuritis ; hereditary ataxia ; 

cerebellar disease. 
Waddling, in progressive muscular dystrophy ; bilateral dis- 
location of the hips; rachitis. 
Hobbling, in osteomalacia. 
Shufifling, in hysterical paralysis. 
Tendon reflexes — 
Knee-jerk.i 

Exaggerated, in spinal or cerebral paralysis, associated 
with ''spasticity" of the muscles (see page 52) ; 
also in transverse myelitis affecting the spinal cord 
above the second lumbar vertebra; cerebellar dis- 
ease; general nervousness. 
Diminished or lost, in spinal or neural affections asso- 
ciated with ''flaccidity" of the musculature (see 
page 52) ; also in transverse myelitis below the 
second or third lumbar vertebra ; hereditary ataxia ; 
"meningismus" (early stage). 
Ankle clonus. ^ 

Absent or very slight, in good health. 



1 Obtained by a sharp blow over lig-amentum patellae, while lower 
leg hangs loosely down. 

2 Rhythmic oscillation of the foot, elicited by abruptly pressing 
toes upward with one hand, while supporting the leg with the other 
hand. 



THE EXTREMITIES. 



0/ 



Present, and often very pronounced, in cerebral hemor- 
rhage ; spastic spinal paralysis ; dorsal myelitis ; dis- 
seminated lateral sclerosis ; hysterical paralysis ; 
tetanus. 
Periosteal reflex.-^ 

Slight, in good health. 

Greatly exaggerated, in cerebral hemorrhage. 
Kernig's sign (inability to extend legs when thighs are 
flexed on abdomen): in divers forms of meningitis; 
occasionally in typhoid fever. 
Babinski's reflex (extension of great toe with flexion of 
other toes on touching sole of foot) : pathognomonic 
of meningitis in children over two years of age; in 
organic hemiplegia. 



WEIGHT AND LENGTH OF A CHILD. 

An authentic record of the gain or loss in weight of the 
patient is invaluable in the diagnosis, prognosis and treat- 
ment. There is no absolute standard for the normal weight or 
height of an infant or older child. To a great extent it depends 
upon the race the child descends from and also upon family 
disposition. Furthermore the size of the child is not always 
an indication as to his inherent vigor. Ordinarily boys are 
heavier than girls. 

Table of Comparative Weight and Height of a Normal Child. 



AGE. 


length. 


weight. 




age. 


LENGTH. 


WEIGHT. 


Birth. 


19.5 


Inches. 


7 Pounds. 


2 


Years. 


32 


Inches. 


26 Pounds 


1 Month. 


20.5 




IVa " 


3 


" 


35 


" 


31 




2 Months 


21. 




9/3 '• 


4 


a 


Z^ 


'■' 


35 




3 " 


22. 




n 


5 


" 


41 


" 


40 ' 




4 " 


23. 




12/ " 


6 


"■ 


44 


" 


45 ' 




5 " 


23.5 




14 " 


7 


" 


46 


u 


49 ' 




6 


24. 




15 " 


8 


'' 


48 


" 


54 ' 




7 


24.5 




16 '• 


9 


'' 


50 


" 


60 ' 




8 " 


25. 




17 " 


10 


'' 


52 


"■ 


65 ' 




9 " 


25.5 




18 " 


11 




54 


" 


71 ' 




" 


26. 




19 " 


12 


'' 


56 


" 


80 ' 




LI 


26.5 




20 '' 












L2 "• 


27. 




21 " 















Weight is — 

Diminished, rapidly, in cholera infantum ; acute febrile dis- 
eases ; chronic wasting diseases, especially tuberculosis, 
malignant growths and suppurative processes ; in diabetes. 

^ Jerk of hand or forearm produced by a tap upon the tendons of 
the supinator longus and biceps — at lower end of the radius and ulna; 
or of the triceps tendon at the olecranon. 



58 



EXAMINATION OF THE PATIENT. 



Slowly, in dyspepsia ; organic affections with slow course, 
e.g., heart and kidney diseases. 
Increased, rapidly, in adipositas, cretinism, anasarca. Slowly 
in normal health. 

Height is — 

At a standstill, in infantilism, cretinism, severe rachitis, and 

in marked central paralysis. 
Increased, rapidly, in acute febrile diseases, especially typhoid 

fever. Slowly, in normal growth. 



WEEK OF WEEK OF AGE 

AGE 2 4 6 8 10 12 M ie 18 20 22 24 26 28 30 32 34 36 38 40 


19 
18 
17 
16 
15 
14 
Sl3 

11 
10 

9 
8 

7 
6 


















































































19 
18 
17 
16 
15 
14 

11 

10 
9 
8 

7 
6 
5 








































































































































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/ 








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Fio-. 21.— Weisfht Chart. 



CHAPTER II. 
Prevention and Control of Disease. 



The Avarfare between health and disease evoh'es Avith The warfare 

between 

inceDtion of life of the oro-anism. The battle is lierceh' ram- health 



&' 



and disease. 



Survival 
of the 

strongest. 



pant and eA'erlasting, the victory at best but temporary. 
Supremacy of health OA^er disease fluctuates AA'ith the amount 
of inherent strength of the indiA'idual, the natural and acquired 
poAA'er of resistance, and the assistance receiA'ed through 
prophylaxis and therapeusis. 

Xature aims to exterminate the AA'eak, and ri^-ht at birth 
tests the A'itality of the infant in a manner most hazardous to 
its subsistence. Thus, accustomed to the ideal domicile of 
the maternal uterus — protected from traumatism and atmos- 
pheric A'icissitudes, nurtured AA^thout elTort and animated 
Avithout the touches of pain or distress — the neAA'born is sud- 
denly cast upon its OAAm resources into a sphere of eternal 
strife, AA'here eA'ery organism, CA^ery element, is struggling for 
supremacy, and Avhere the strongest — not iuA'ariably the fittest 
— triumphs. 

INHERENT STRENGTH. 

Inherent strength is essential to actiA'e life, to maintenance 
of perfect health. A pOAA^erful constitution aa'III OA'ercome an 
attack of disease that aa^II fell the AA'eak and the frail. A 
strong organization AA'ill surmount hardships and rapidly 
recuperate after protracted illness. Inherent strength is not 
procurable after birth. It is a consummation, an inheritance, g^J^^^^^J^^ 
of ancestral A'irility and A'igor, premarital purity, conjugal 
dcA'otion, matrimonial chastity, sobriety and ideal hygiene. It 
can be fostered by regulation of marriage, conserA'atiA'e mutual 
selection, prohibition of consanguineous marriages and those 
encumbered by graA'e disease, habits, alcoholism and drug 
addictions, or extreme pOA'erty. Finally, it can be greatly 
improA'ed by judicious management of pregnancy. 

(59) 



Fostering oi 



Natural and 



60 PREVENTION AND CONTROL OF DISEASE. 

POWER OF RESISTANCE AND SUSCEPTIBILITY. 

Immunity, protection, or power of resistance against dis- 
ease, and to a slighter extent also susceptibility toward 
disease, may be natural or acquired. It varies in different 
individuals and in the same individual at different periods of 
acquired, life. Natural or congenital immunity is aptly exemplified by 
the comparatively rare occurrence of communicable diseases in 
infants under three months of age. Congenital susceptibility 
is demonstrable by the prevalence of certain affections in some 
families or races, e.g., hemophilia, amaurotic family idiocy and 
the like. In contrast to inherent vitality, acquired power of 
resistance is vastly influenced during the life of the child. 
Thus, immunity against communicable diseases is often tem- 
porarily or permanently conferred, naturally by a previous 
attack of the same malady {e.g., yellow fever, pertussis), and 
artificially by: 1. Suitable nutrition. 2. Hygiene and sanita- 
tion. 3. Immunization. 4. Drugs and physical therapeutic 
measures. 

I. NUTRITION. 

Suitable nutrition is indispensable to the life and growth 
of the individual and to the maintenance and advancement of 
his power of resistance. The human economy demands for 
its sustenance a liberal supply of proteids (to build up and to 
nutrition, reconstruct the tissues), fat and carbohydrates (to produce 
energy and heat), mineral salts (to help formation of bones 
and teeth), and water (to aid the solubility of the food ele- 
• ments and the excretion of waste products). An ideal food, 
therefore, must contain these five ingredients in more or less 
definite proportion, must be readily digestible and assimilable, 
and be free from pathogenic bacteria. 

WOMAN'S MILK.i 

Woman's milk is a highly nutritious, biologically as yet 

somewhat mysterious product, destined by nature to serve as 

the food-supply alike for the rich and the poor, the weak and 

Nature's the strons: infant under nine months of age. It not only coni- 

infant food. . , , r • , ,• • • • i i • 

plies with the aforementioned qualitative requisites, but being- 
ready for immediate consumption — without previous pasteur- 



Elements of 



1 For its approximate composition, see footnote, page 68. 



NUTRITION. 



61 



ization, sterilization or modification — at all hours of the day 
and at all seasons of the year, it is also the most convenient 
and satisfactory food from an economic point of view. Infants 
reared on woman's milk are almost invariably healthier, 
stronger and less troublesome than those that are bottle fed. 



Ever 
ready. 




Fig. 22. — Microscopical Appearances of Woman's Milk. 
(After Fleischman.) A, Poor milk, showing preponderance of 
large fat globules and a pancit}^ of fat. B, Normal milk, showing 
the preponderance of medium-sized fat globules. C, Poor milk; 
a paucity of fat and an almost granular state of the fat globules. 



With suitable management they are, as a rule, free from gas- 
troenteric affections, scurvy and rickets, and present greater 
power of resistance to communicable diseases. 



62 



PREVENTION AND CONTROL OF DISEASE. 



MATERNAL NURSING. 



Mother's 
duty. 



Prerequisites. 



Care of ttie 

prospective 

motlier. 



Liberal 
fluid diet 

during 
nursing. 



For the reasons just given, and in view of the facts that 
wet-nurses are expensive luxuries, are often unreliable, and 
may at some time during the nursing period, through unscrup- 
ulous and impure contact, contract and convey a disease to her 
charge, it is the solemn duty of every healthy mother to 
endeavor to nurse her offspring, wholly or partially, even if it 
be only for a brief period of time. 

Successful maternal nursing presupposes, in addition to 
general good health of the mother, well-developed breasts and 
nipples and an ample supply of rich milk. These qualifica- 
tions are rarely met to perfection with women of large cities, 
where the extravagancies of extreme wealth or the misery of 
extreme poverty sap their vital forces. A great deal, however, 
can be accomplished by judicious management of the mother 
during pregnancy and parturition. 

The prospective mother should be placed in the most 
healthful physical and mental condition. Her diet should be 
liberal, her living rooms spacious and airy and her surround- 
ings cheerful. She is to be free from anxieties of a livelihood 
and the pompous frivolities of wanton society. The primipara 
should be taught to realize that pregnancy and parturition are 
physiologic processes, ordinarily devoid of perilous complica- 
tions or sequelae. 

Toward the end of pregnancy the breast nipples should 
be elongated by gentle traction with the fingers or pump, and 
cleansed and hardened by means of hot boric acid solutions, 
cognac, glycerite of tannin, and the like. . To insure an ample 
supply of breast milk after delivery, in addition to complying 
with the aforementioned suggestions, a liberal fluid diet con- 
sisting principally of rich cows' milk, cornmeal and oatmeal 
oTuel cooked in milk, malted milk, etc., forms the most efficient 
adjuvant. At a later period the dietary of the nursing mother 
should be increased by a liberal allowance of meat, eggs, vege- 
tables and other nutritious food-stuffs to which she was 
ordinarily accustomed. 

Light outdoor exercise, regulation of the boAvels, avoid- 
ance of fatigue and nerve disturbances, all serve well to 
improve the health of the mother and the quality of her milk, 
and indirectly the welfare of the baby. 



NUTRITION. ■ 63 

One other special advantage of maternal- over wet- 
nursing is the benefit the newborn derives from the consump- 
tion of the provisional milk secretion — the colostrum. This 
deep yellow, strongly alkaline and albuminous fluid which 
forms the mammary secretion during the first three or four 
days after labor, not only acts as a laxative — which is badly 
needed — but being small in quantity it also serves to moderate 
the greedy appetite of the infant and prevents early overfeed- 
ing, the usual cause of infantile colic. 

The nursing of the baby is generally begun with about 
eight hours after delivery, or later if the mother has not fully 
recovered from the painful and fatiguing ordeal. During the 
first few days the infant is applied to the breast every three 
or four hours and afterward every two and a half hours. It 



Colostrum. 




Time for 



Fig. 23. — Breast Pump. 

should not be awakened for a feeding if sound asleep (except 
when very weak and delicate), and unless very restless should 
be left alone from 10 p.m. to 5 a.m. It should be nursed from nursing. 
fifteen to twenty minutes at a time, alternately on one and the 
other breast, or on both breasts if the milk secretion is scanty. 
From six weeks on the infant should be fed every three hours, 
and less frequently when it reaches six months of age. Be- 
tween nursing the baby may receive a few ounces of warm, 
slightly sweetened water. 

Before and after each feeding the breast nipples should be 
carefully cleansed with a warm saturated solution of boric 
acid. 

If the breast nipples are short, sunken or cracked, we must 
temporarily resort to an artificial nipple or breast pump (see 
Fig. 23). The latter device is also employed where the infant 
is too weak to pull, or refuses to make an efifort to do so. In 
very delicate infants, e.g., prematures, it is often necessary to 



Use of 
breast 
pump. 



64 



PREVENTION AND CONTROL OF DISEASE. 



withdraw the breast milk with a pumpi and administer it by 
means of a spoon or dropper. 

With the suggestions here offered the majority of healthy 
mothers will be able to nurse their offspring, provided they are 
sufficiently encouraged by the physician and the enormous 
advantages of maternal breast feeding are thoroughly ex- 
plained to them. 

When an infant does not thrive on breast milk, it is impera- 
tive, before resorting to another infant food, to carefully 




Fie. 24.— Holt's Milk Set. 



Analysis 

of breast 

milk. 



analyze the breast milk, and, if possible, to overcome the 
difff culty. We should determine : — 

1. The quantity. — This can readily be learned by extracting 
the milk-supply of one or both breasts, or by weighing the 
infant before and after nursing and noting the difference in 
weight. 



1 A practical method of withdrawing breast-milk is the following: 
Fill a wide-mouthed bottle with boiling water. Then pour the water 
out and cool the mouth of the bottle and apply over the nipple. As 
the bottle cools, the milk spurts from the nipple and the breast is auto- 
matically emptied. The milk is thus ready for use at once, keeping 
warm in the warm bottle. 



NUTRITION. 



65 



2. The quality. — As the sugar is usually found to be normal 
in all cases, the tests are ordinarily limited to the fat and pro- 
tein-contents of the breast milk. After obtaining an ounce 
of what is called "middle-milk" (i.e., the milk collected after 
1 or 2 ounces had been withdrawn) or of the entire breast 
supply, we determine the following qualifications : — 

(a) Reaction — fresh breast milk should be alkaline or 
neutral ; may be tested with litmus-paper. 

(b) Specific gravity — about 1030, taken by means of a 
lactometer, at a temperature of 65° to 72° F. 

(c) Fat content — the cylinder of Holt's milk set (see Fig. 
24) is filled with the sample of breast milk up to the zero 
mark and allowed to stand for twenty-four hours in a room 
temperature of 70°. The percentage of cream is then read ofif, 
bearing in mind that the ratio of the cream to the fat is 
approximately 5 to 3, i.e., 5 per cent, of cream equals 3 per 
cent, of fat. 

{d) Proteids — the amount of proteids is approximately 
determined by the amount of fat and the specific gravity of 
the milk, i.e., high specific gravity, high proteids; low 
specific gravity, high fat. Holt's accompanying table explains 
the application of this principle : — 



Specific Gravity Cream— 24 Hours Proteid (Calculated) 



Average 

Normal variations. ■■ 

Normal variations 

Abnormal variations. 



1031 

1028-1029 

1032 

Low (below 1028) 

Low (below 1028) 

High (above 1032) 

!High (above 1032) 



7 

85^-12^ 

High (above WO 

Low (below 5:0 

High 

Low 



1.5r« 

Normal (rich milk) 

Normal (fair milk) 

Normal or slightly below 

Very low (very poor milk) 

Very high (very rich milk) 

Normal (or nearly so) 



While, as a rule, the breast milk of the modern mother is 
characteristic for its paucity, we occasionally come across 
breast milk that is too rich in quality, especially as regards the 
fat content. In the majority of such instances, if the excess 
in fat is detected early, it can readily be corrected (by reduc- 
ing the mother's diet, encouragement of active exercise, etc., 
or by resorting to partial nursing) before any appreciable 
harm has been done to the infant. In some cases, however, 
the abnormality of the milk is not discovered until the infant 
is suffering from "fat indigestion" (diarrhea with masses of 
fat, eructations, colic and possibly loss of weight), and one 
is often in a quandary as to what is best to do. An attempt 



Reduction 
of fat in 
breast 
milk. 



66 



PREVENTION AND CONTROL OF DISEASE. 



may be made to thin the breast milk by administering to the 

Diluent infant before each nursing 3^ or 1 ounce of plain or cereal 

nursing^ Water. If this procedure and the dieting of the mother fail, 

and the child is progressively getting worse, we must either 

engage a wet-nurse or put the baby on a suitable artificial 

food. 

Where' the milk supply is deficient, partial nursing should 

be insisted upon, preferably alternating one breast- with one 

bottle-feeding. 



Contra- 
indications 
to maternal 
nursing. 



Freely- 
secreting 
breasts. 



WET-NURSING. 

Wet-nurses at best are an evil, but often indispensable, 
where mothers will not, can not, or must not nurse their own 
offspring. If the mother cannot nurse her baby because of 
quantitative or qualitative insufficiency of her milk, there is 
no urgency of securing a wet-nurse, as the milk may be 
improved by a richer diet and better care of the mother, or the 
infant may receive daily two or three feedings of properly 
modified cows' milk. In the event, however, that the mother 
is utterly unable to nurse her baby or is prevented from doing 
it through disease (tuberculosis, cancer; acute, greatly debili- 
tating affections ; advanced kidney or heart disease ; local 
inflammation of the breast, psychoses and the like) or preg- 
nancy, a wet-nurse is the best substitute. The wet-nurse to 
be chosen must undergo a very careful physical examination, 
first as to the secreting quality of the breasts and the condi- 
tion of the nipples, and next as to her general health. 

The secreting quality of the breast is best tested by grasp- 
ing it with the thumb and four fingers and, while moving the 
whole hand somewhat forward, exerting uniform but gentle 
pressure. With this manipulation the milk should escape 
from the breast in several even jets for from fifteen to thirty 
seconds. Too much reliance should not be placed upon the 
form of the breast, for even pendulous, cylindrical, or conical 
breasts are occasionally poor milk producers. On the other 
hand, an abundance of glandular parenchyma oft'ers more 
reliable guarantee as to its secreting power. The physician 
should be on his guard that the abundance of milk is not the 
result of the breast having been allowed to fill up for several 
hours previous to the examination — a fact recognized by the 
presence of pain on pressure and intense distention of the 



NUTRITION. 67 

mammary ducts. The nipples should be hard, long and bulky, condition 

r r • iz ot nipples. 

free from seuere erosions or nssures. 

The quality of the milk is not near as essential as the 
quantity, since the former can usually be improved upon by a 
suitable diet and good hygiene. 

The following diseases render a wet-nurse useless : Tuber- 
culosis, whether local or general ; syphilis, in all its stages (not indications 



to wet- 



necessarily the mother) ; non-compensating heart disease, 
grave affections of all other bodily organs ; profound anemia ; 
intractable, communicable skin, hair, eye diseases; gonorrhea; 
suppurative processes of the bones; mastitis (not necessarily 
the mother) ; ozena, drug-addiction, psychoses, and epilepsy. 

The possible presence of syphilis should receiA^e especial 
attention. Corona veneris, bony tumefactions, nasopharyn- Guard 
geal patches, old ulcers and scars, enlarged glands (especially syphilis, 
paramammary, epitrochlear, and inguinal) should invariably 
arouse the suspicion of the examiner. 

The wet-nurse of choice should be one between 20 
and 30 years old, who has given birth to two healthy chil- 
dren and nursed one successfully, the age of the last child being 
nearly the same as the one she is about to nurse. The diet of 
the Avet-nurse, the care of her breasts and nipples, the mode of 
living, exercise, etc., should be the same as in a nursing mother 

ARTIFICIAL FEEDING. 

Where maternal nursing is impossible, and wet-nursing 
impracticable, there is nothing else left but to resort to 
artificial feeding. All human ingenuity and skill have thus 
far failed to provide a food for infants that is as nutritious, 
digestible, sterile Avithout interference of composition, and 
as economic as woman's milk. 

With suitable modification cowls' milk forms the best 
substitute for human milk. But it is a poor substitute at best, Sr^best 
for not alone does human milk vastly difi:"er from cows' milk 
in the quantitative proportion of the essential chemical 
ingredients, but the latter A^ary greatly also qualitatiA^ely. 
Furthermore, human milk contains scA'eral as yet not fully 
determined biological constituents, especially enzymes, Avhich 
are absent in coavs' milk. 



substitute. 



68 



PREVENTION AND CONTROL OF DISEASE. 



COWS' MILK FEEDING. 



Differences 

between 

cows' and 

human 

milk. 



Reduce 
proteids. 



meet the aforementioned requirements of an infant 
cows' milk must undergo elaborate modification, so that 



To 
food 

its composition conforms, quantitatively and qualitatively, as 
closely as possible to that of human milk.i To accomplish this 
object, it is, of course, essential to have a clear appreciation of 
the most important differential peculiarities between the two 
kinds of milk involved. 

1. Human milk contains approximately half as much pro- 
teids as cows' milk. 

(a) The proteids of human milk are composed of 61.5 per 
cent, of casein and 38.5 per cent, of albumin against 85.7 per 
cent, of casein and 14.3 per cent, of albumin in cows' milk. 
That is, in a ^iven quantity of milk, out of the total proteid 
content, human milk contains approximately 58 parts of 
albumin and 92 parts of casein, while cows' milk contains 42 
parts of albumin and 258 parts of casein. 

{h) The casein of human milk in the stomach forms loose, 
flocculent curds, which dissolve readily. On the other hand, 
the casein of cows' milk coagulates in large, firm clots which 
are dissolved slowly. 

2. Human milk contains 1 to 2 per cent, more sugar than 
cows' milk. 

3. Human milk is sterile, cows' milk replete with bacteria. 

4. Human milk is alkaline in reaction, cows' milk neutral 
or slightly acid. 

In addition to these differences human milk contains less 
volatile fatty acids than cows' milk, and its salt content, while 
considerably smaller than that of cows' milk, is comparatively 
richer in iron. With these observations in view, the prin- 
ciples involved in the modification of cows' milk as a suitable 
infant food are quite obvious. We have to — 

1. Reduce the proteids, and more especially render the 
casein more easily digestible. 

This can in part be accomplished by dilution. ^ There 



1 Approximate Composition of Human and Cows' Milk. 

Proteids. Fat. Sugar. Salts. Water. 

Human Milk 1.50 4.00 6.00 0.20 88.80 

Cows' Milk 3.00 4.00 5.00 0.70 88.30 

2 Diluents. — These are employed with the objects in view : firstly, 
to thin the milk and thus to reduce the percentage of proteids; secondly, 
to break up the curd of the casein of cows' milk formed in the infantile 



XUTRITIOX. 69 

being twice as much of proteid in cows' milk as in human 
milk, we can add one part of a diluent to ever}' one part of the 
cows' milk to equalize the proteid value. B}' doing so we 
obtain a mixture containing approximately 

Proteids 1.50 per cent. 

Sugar 2.50 per cent. 

Fat 2.00 per cent. 

which, while fairly correct in its content of proteid, is greatly 
deficient in sugar and fat. Our next effort, therefore, must be 
to — 

2. Increase the sugar as well as the fat — both of which Add sugar, 
having undergone reduction by dilution. 

The sugar can readily be replaced by the addition of either 
cane-sugar (enough to sweeten — about 15 grains) or milk- 
sugar (about a third of a teaspoonful, or 22 grains, to every 
ounce of the diluent). The fat may be increased either by 
adding cream, or, preferably, using top-milk-" as a base, i.e., 

stomach. Plain water serves the first purpose, i.e., reduces the proteid 
content of the milk, but has no appreciable effect upon the curd. On the 
other hand, cereal gruels (carbohydrates') of barley, oatmeal, arrowroot, 
rice, farina, wheat flour and the different carbohydrate infant foods or 
''milk modifiers'" on the market, answer both requisites. As the capacity 
for starch digestion in infants under three months of age is ver}' poor, it 
is not advisable to overburden the young infantile stomach with these 
products. Small quantities of cereal gruels, however, may be employed 
with safety and benefit, hi infants over six months the diluent may be 
made up wholly of either barley or oatmeal water — the former especially 
in the presence of diarrhea, the latter in constipation. 

Mode of Preparation of Diluents for Cows' Milk. — Barley-z^'afer. 
— One tablespoonful of prepared barley (Robinson's) is rubbed up in a 
little cold water: to this is gradually added a pint of boiling hot water, 
and the mixture is allowed to boil slowly (simmer), with constant stirring, 
for about tw-enty minutes and then strained. Boiled water is then 
added sufficient to make one pint. 

Oatmeal-wafer. — One tablespoonful of oatmeal is rubbed up in a 
little cold w^ater : to this is added a pint of boiling hot water and aliovved 
to boil slowdy (simmer) for one to two hours, wath frequent stirring, and 
strained through gauze. Boiled water is then added sufficient to make 
one pint. 

Rice-zvater. — One tablespoonful of ground rice to a pint of water, 
prepared the same as oatmeal water. 

3 Top-milk. — Bottle-milk, as obtained from reliable milk dealers, 
contains approximately the following percentages of fat and proteids : — 
Portion Taken. Fat. Proteids. 

Upper y2 ounce. 24.8 ,3.1 

1 " 23.1 3.2 

2 " 21.4 Z.Z 
4 " 20.1 3.4 
6 " 18.6 3.5 
8 " 16.7 3.6 

12 " 12.1 ?,.7 

" 16 " 8.4 3.8 

" 18 " 6.5 3.9 



70 



PREVENTION AND CONTROL OF DISEASE. 



by taking instead of "whole" milk a sufficient quantity of milk 
out of the upper 18 ounces of a bottle (which contains 
about 6 per cent, of fat) decanted for this purpose and 
thoroughly shaken. 

Now, then, by taking one ounce of milk, one ounce of a 
diluent and a third of a teaspoonful of milk sugar, we obtain a 
mixture of milk approximately of the following composition : 

Proteids 1.50 per cent. 

Sugar 6.00 per cent. 

Fat 2.00 per cent. 

Which, though still deficient in fat (the fad of high percentages 

of fat has, as a result of frequent 
occurrence of "fat indigestion" 
in infants, lost its strongest ad- 
vocates), is nevertheless amply 
nutritious and well tolerated by 
infants. 

3. Render the milk alkaline. 
For this purpose we resort to 
either ^ grain of sodium bicarb, 
to every ounce of milk or to 5 
per cent, of lime-water. Both of 
these preparations have the addi- 
tional qualification of prevent- 
ing the casein from coagulating 
into tough curds. 1 

4. Obtain and maintain milk 
at a certain standard of clean- 
liness and insure the absence of pathogenic bacteria. 

It is well to bear in mind that the milk of a healthy cow 

is as free from bacteria while still in the udder as that of a 

Contamination woman in the breast. Contamination of cows' milk occurs 

of cows 

milk, from local affections of the udder or the teats, dirty utensils, 
the dust of the stable, the hands of the milker or others engaged 
at the dairy, from flies or insects, droppings of particles of 
manure from the tail or belly of the cow, from polluted water 
employed in adulterating the milk, etc. The rendering of milk 
free from bacteria, therefore, must begin long before the milk 
has been distributed to the consumer. 




Fig. 25. — Chapin's Dipper for 
Removal of "Top-milk." 



1 Sodium citrate (gr. ij to every ounce of milk) answers the same 
purpose. 



NUTRITION. 



71 



The cow must be free from disease, especially from tuber- 
culosis as determined by the tuberculin test and by regular 
inspection by a competent veterinary surgeon. 

The cow's entire body should be groomed daily, and 
immediately before milking the belly, tail, and particularly the 
udder should be carefully cleansed with a clean, damp cloth, 
with or without soap, and dried with a clean towel. 

The milker must be free from communicable affections. 
Before milking he should thoroughly scrub and dry his hands 
and don clean, washable, outer garments. He should have a 



Cleanliness 
of the 
stable, 
cow, and 
milker. 




Fig. 26. — Arnold Steam Sterilizer. 



few of these on hand, in order to change them should one gown 
or suit accidentall}^ get soiled in the act of milking. 

The milk of each cow should be collected separately in 
sterile utensils and immediately removed from the stable to a 
specially clean place reserved for the keeping of the milk until 
ready for shipment. 

The milk should be rapidly cooled (below 45° F.) and 
strained through a sterile strainer, then bottled, closed with 
sterile discs, capped, and finally iced — all within an hour or so 
after milking. 

After reaching the consumer, which, owing to the rapid 
development of bacteria in milk over twenty-four hours old, 
should occur within this period of time, the milk is further 
kept on ice until needed for the preparation of the food. 

If, notAvithstanding all the prophylactic measures, some 



Cooling 
of milk. 



72 PREVENTION AND CONTROL OF DISEASE. 

doubt still remains as to the sterility of the milk, we must sub- 
ject it to sterilization or pasteurization. i 



Modification 

of milk to 

meet the 

needs of the 

individual 

baby. 



LABORATORY AND HOME MODIFICATION 
OF COWS' MILK. 

We have just learned the numerous essential differences 
of composition that exist between human and cows' milk, and 
the means by Avhich the differences can be removed. Were it 
merely a question of obtaining milk of a definite uniform, com- 
position which w^ould at once prove suitable for the feeding of 
infants of all ages, the problem of artificial feeding of infants 
would long have been solved. Unfortunately this is not the 
case. Not only must cows' milk be modified so that its prin- 
cipal constituents as closely as possible resemble those of 
human milk, but it must undergo also specific modification to 
meet the digestive powers and the requirements of the individ- 
ual infant at certain periods of life — quite a difficult proposition 
indeed, yet within the scope of execution. 

Thanks to the rapid strides of physiological chemistry, and 
the good will and enterprise of several milk dealers and labora- 
tory chemists, the modification of cows' milk as an infant food 
has almost reached a stage of perfection. With the help of the 
laboratory chemist, the physician is now enabled to write a 
prescription for a food mixture of definite composition and, 
like a drug in the pharmacy, have it compounded exactly as 



1 Sterilization and Pasteurization. — Both of these processes are 
accomplished by means of one of the many sterilizers on the market. In 
sterilising the milk is heated for about fifteen minutes at a temperature of 
212° F. ; in pasteurising, for about forty minutes at a temperature of from 
140° to 150° F. For infant-feeding the milk should undergo the heating 
process after it has been modified and divided in the requisite number of 
feeding bottle for the entire 24 hours. The bottles are cooled off 
by allowing cold water slowly to run through the sterilizer ; they are then 
tightly corked, preferably with non-absorbent cotton, and placed on ice until 
needed for use. Before feeding the bottle should be warmed to body heat. 
Except during the hot summer months or when there is good reason to 
believe that the milk harbors virulent bacteria (e.g., during epidemics of 
typhoid, cholera, etc.), sterilization is nowadays rarely practised. Pasteur- 
ization is usually resorted to instead, particularly since it has been demon- 
strated that this process is less apt to change the taste of the milk, to 
interfere with its digestibility, and to cause constipation. The view held, 
especially by overenthusiastic, though well-meaning, laymen, that pasteur- 
ized milk is as nutritious as clean, fresh, raw cows' milk, is not based upon 
scientific observation. Quite the contrary ; pasteurized milk lacks several 
nutritive and protective elements that exist in fresh cows' milk. Hence, 
its continued use greatly interferes with the growth and development of 
the infant, and is not rarely productive of rickets and scurvy. 



XUTRITIO: 



ordered. The latitude of composition is well illustrated in the 
prescription here appended : — 



Fats 

Carbohydrates— lactose (milk-sugar) 


Per c 
2 
6 


ent. 


Number of 

feedings 7 
Amount at 

each feeding 4>^ 

Other diluent— Barley-water 
Heat at 


s 


T^ . -^ SWhey 




75 
75 




ProteidsJ(.^|J^;;;;;;;;;;;;;;;;;;;;;;;;;; 




dU'a 


Peptonize 






Lime-water 'c of total mixture 


5 








op 




Raw 

i 
1 




Sodium citrate j ,- ^^ ^^^^j mixture 
















Sodium bicarb. ^ ,^ ^^ ^^^^ mixture " ' ' 








Lactic acid \ 
bacillus J 









A\ hen 'laboratory milk is not obtainable and "home modi- Home 

i- • V 1 1 ' 1 1 - -I- 1 • modification 

tication' has to be resorted to, we can orreatlv lacilitate this of cows' 

11- 1 1 • rr 1 - ^ • • • milk, after 

process and obviate the difficult task o± memonzms: compli- standard 

1 - 1 , 1 • -11 - , . . , formula. 

cated tormulas by selecting a milk tormula ol simplest com- 
position (1:1, i.e., 1 ounce or its multiple of milk to 1 ounce or 
its multiple of a diluent, in Avhich are included one teaspoonful 
of lime-Avater for every ounce of milk, and one-third of a tea- 
spoonful of milk-sugar for every ounce of the diluent) and pre- 
paring the other milk mixtures by modifying this ''standard" 
formula. 

Directions. — 1. Bear in mind the standard formula (1:1), 
which is intended for babies six months old. 

2. For infants under six months increase (about every tw^o 
months downward) the diluent by one ounce or its multiple, 
using "top milk" as a base and plain or cereal water as the 
diluent. 

3. For infants OTer six months of age, increase (every two 
months upward) the milk by one ounce or its multiple, using 
''whole milk" as the base and cereal water as the diluent. 

4. Include in the diluent one teaspoonful of lime-water for 
every ounce of milk, and add one-third of a teaspoonful of milk- 
sugar for every ounce of the diluent. 

In accord with these directions the following milk foririulas 
are obtained : — 



PREVENTION AND CONTROL OF DISEASE. 



1:2 




2:1 


four months 




eigfht months 


1:3 




3:1 


two months 


Standard Formula 

1:1 

for an infant six months old. 


ten months 


1:4 




4:1 


one month 




twelve months 


1:5 


- 


5:1 


half a month 




fourteen months 



Milk modified in accordance with this table yields mixtures 
approximately of the following composition : — 

For an infant 2 weeks old — (1:5), 

Top milk 1 ounce Proteids. . . . 0.50 

Lime-wateri 1 dram Sugar 6.00 

Diluent (water) 5 ounces Fat 1.00 

Milk-sugar 1% drams 

For an infant 1 month old — (1 :4). 

Top milk 1 ounce Proteids — 0.60 

Lime-water 1 dram Sugar 6.00 

Diluent (water) 4 ounces Fat 1.20 

Milk-sugar 1% drams 

For an infant 2 months old — (1 :3). 

Top milk 1 ounce Proteids 0.75 

Lime-water 1 dram Sugar 6.00 

Diluent (25% barley water) ... 3 ounces Fat 1.50 

Milk-sugar 1 dram 



For an infant 4 months old — (1:2). 
Top milk 1 ounce Proteids 



Lime-water 1 dram 

Diluent (50% barley water) 2 ounces 

Milk-sugar % dram 



1.00 

Sugar 6.00 

Fat 2.00 



For an infant 6 months old — (1: 1).^ 

Whole milk 1 ounce Proteids 1.50 

Lime-water 1 dram Sugar 6.00 

Diluent (barley water, 75%)... 1 ounce Fat 2.00 

Milk-sugar % dram 



For an infant 8 months old — (2:1). 



Whole milk 2 ounces 

Lime-water 2 drams 

Diluent (barley water) 1 ounce 

Milk-sugar % dram 



Proteids.... 2.00 

Sugar 6.00 

Fat 2.33 



1 To simplify the formulas the lime-water is not included in the 
diluent. 

2 Standard formula. 



NUTRITION. 

For an infant 10 months old — (3:1). 

Whole milk 3 ounces Proteids .... 2.25 

Lime-water 3 drams Sugar 6.00 

Diluent (barley water) 1 ounce Fat 3.00 

Milk-sugar y^ dram 

For an infant 12 months old — (4:1). 

Whole milk 4 ounces 

Lime-water 4 drams 

Diluent (barley water) 1 ounce 

Milk-sugar % dram 



/O 



Proteids.. 

Sugar 

Fat 


. 2.40 

.. 6.00 

. 3.20 


). 




Proteids. . 

Sugar 

Fat 


. 2.50 
. 6.00 
. 4.00 



For an infant 14 nwntJis old — (5:1) 

AA'hole milk 5 ounces 

Lime-water 5 drams 

Diluent (barley water) 1 dram 

Milk-sugar % dram 

It is quite obvious that the method of home modification of 
cows' milk^ just described, is very far from being exact. The 
same, however, applies also to all the other methods in vogue. 
The latter, furthermore, have the disadvantage of requiring Advantages 
the knowledge of higher mathematics for their compilation, method. 
It will be noted that the milk mixtures, especially those 
intended for infants under six months of age, are comparatiA^ely 
poor in proteids and fat. From my extraordinarily large 
experience in infant feeding, as chief of one of the milk depots 
of the Charity Organization Society, I have learned to know 
that infants invariably do better on weak mixtures than on 
stronger ones. With the advance of the infant's age and its 
demands for a more liberal food supply the latter can readily 
be furnished by a moderate allowance of other articles of food, 
such as bread, soup, cereals, eggs, etc., as fully outlined in 
this chapter (see page 80). 

QUANTITY OF FOOD. 

The keynote to successful feeding is avoidance of overfeed- 
ing. Infants almost always act hungry, though in reality are varies with 
so only at certain times. Colicky babies particularly never ba^y°and 
seem to have enough of food, and the more they drink the 
greater the colic and z'ice versa — the old story again of the 
''vicious circle." The amount of food needed by the healthy 
infant is best judged by the capacity of its stomach. This is 
subject to great variation, ranging vastly not alone with the 
age of the infant, but also with its general development and 
the state of tonicitv of the muscular walls. 



capacity of 
stomach. 



PREVENTION AND CONTROL OF DISEASE. 



as 



0^ .2 



a a 



a o. 

bt XT. 

M 0) 



h4 ?: 






1—1 1—1 CN 



CN CM CO CO rf 



\^ ^D ^O "sO ^O 



1-1 <M C^ (M CN 



O. -^ CO CO CN 























ce 










rJrJ 










t 


. 




■^ 


O 


OO 


O 


t-^ 


"* 


CO 


• 










1— ( 








U 




















u 




















Q> 




rtlCKl 


.^!c^ 


coi^ 












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CO 


lO 


CO 


ON 


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■-1 




















a» 














n\rr 




-Ji,~] 


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T— 1 


OO 


CO 


Tf 


r^ 


j:5 










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CNJ 


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^i-*< 


■-t) 












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<.^ 



NUTRITION 



/ 1 



stomach 



The child should receive with each feeding as much food as 
the stomach will hold^ minus half to two ounces to avoid ^^p'^^^*^^- 
its overflowing-. It is practicable to prepare, every morning, 
the total amount of food for twenty-four hours; to divide it in 
the requisite number of feedings in separate bottles, corked 
with non-absorbent cotton, and — preceded or not by steriliza- 
tion or pasteurization — to place it and keep it on ice until 
needed for feeding. 

As a rule, properly modified milk in suitable quantities 
agrees well with the great majority of infants, especially if 
its administration is started long before their digestive tracts 
had been ruined by the domestic feeding-panaceas — which, 
as usually, served to "make bouncers" of some neighboring- 
children or "raised a family of twelve." However, occasion- 
ally infants do show a certain idiosyncrasy to cows' milk, 
regardless of its quality or quantity, and if a wet-nurse is not 
procurable, we have to resort to other food preparations to 
sustain the infants' lives — perhaps long enough until modified 
milk is tolerated. 

COWS' MILK SUBSTITUTES. 

Dift'erent milk substitutes and milk modifiers have from 
time to time been recommended in "difficult feeding cases." 
We will enumerate them in the order of their usefulness. 

Malt-soup. — Two ounces of wheat flour are slowly and 
thoroughly mixed with one pint of milk, and strained through 
gauze. In a second vessel three ounces of thick malt are dis- 
solved in a pint of warm water to which had been added 
fifteen grains of carbonate of potassium. Now both solutions 
are mixed together and heated very slowly up to a boil. For 
delicate infants this preparation may be diluted by an equal 
or smaller quantity of water. Malt-soup is. often particularly Dyspepsia 
beneficial in underfed, dyspeptic and rachitic babies. If well marasmus, 
tolerated it may be continued for several months. 

As the infant improves and can tolerate a heavier food, the 
quantity of milk may gradually be increased — zvitJwut a cor- 
responding addition of flour or malt. 



1 The following fairly represents the average capacity of the infantile 
stomach: At the end of the first week, 1 ounce; the second week, 2 
ounces; first month, 3 ounces; second month, 4 ounces; fourth month, 5 
ounces ; sixth month, 6 ounces; eighth month, 7 ounces; tenth month, 8 
ounces; twelfth month, 9 ounces; fourteenth month, 10 ounces. 



78 PREVENTION AND CONTROL OF DISEASE. 

Condensed Milk. — Where the principal difficulty consists in 
incapacity to digest cows' milk casein, condensed milk^ will 
be found to act kindly, since the consistency of the coagu- 
lum of condensed-milk casein formed in the infantile stomach 
greatly resembles that of human milk. It has also the advan- 
tages of being inexpensive and not as readily subject to 
contamination as ordinary cows' milk. However, containing 
as it does about 51 per cent, of sugar, and requiring eight to 
ten times dilution to approximate the sugar content of human 
milk, the simultaneous reduction (by dilution) of the fat and 
proteid contents to about 1 per cent, and l}i per cent. respect- 
Asa ively renders condensed milk too poor in quality to serve 

temporary j. j. ^ 

food, as an ideal infant food. Indeed, it is usually found that infants 

over three months fed on diluted condensed milk soon contract 

rachitis. Nevertheless, as a temporary food, especially during 

the summer months or a long journey, it is invaluable. As 

already suggested condensed milk should be administered in 

quantities appropriate for the infant's age, in dilution with 

from eight to ten or even twelve parts of plain or cereal 

water. The deficiency of fat may be supplemented by the 

addition of cream. 

Whey. — Where the digestive capacity of casein is greatly 

at fault, we may temporarily resort to whey feeding. Whey 

is obtained by adding to a pint of fresh warm (100° F.} milk 

two teaspoonfuls of essence of pepsin. After it stiffens beat 

up the curd with a fork and strain through a few layers of 

gauze so as to withhold the coagulated casein. The decanted 

liquid contains approximately: — 

Proteids. Sugar. Fat. 

Lactalbumin 0.9% 4.5% 0.5% 

Casein 0.3% 

By adding a little sugar to overcome its deficiency and 

employing a cereal diluent instead of plain water, the whey 

mixture is amply nutritious to sustain an infant's vitality for 

In diarrhea several wccks or mouths. Whey is most useful in di8"estive 

and . , , ... 

proteid disturbances requiring: low proteids, in mixed breast- and 

indigestion. ,,.,. . ^ .-i i- r t 

bottle-feedmg, m summer diarrheas, and m acute fevers, in 
fact, one of the principal advantages of "laboratory milk" is 
the adoption of whey as its chief proteid component. 



1 Approximate composition of condensed milk : — 
Proteids. Sugar. Fat. Salts. Water. 

8.00 51.00 7 1.50 32.00 



NUTRITION. 79 

Buttermilk. — This is prepared by thoroughly mixing, in a 
suitable agate vessel, one quart of fresh, rich milk, with a 
pint or less of water, a pinch of salt, and the pure lactic acid 
culture (any of the pure mercantile lactic bacilli tablets 
answers the purpose). The vessel is covered with a thin cloth 
and allowed to stand in the room (70° to 80° F.) for from 
eighteen to twenty-four hours. It is now placed on ice until 
needed. For infant feeding we add to every quart of butter- 
milk a flat tablespoonful of wheat-flour and two tablespoonfuls 
of cane-sugar and allow the mixture to boil over a low fire, for 
two to three minutes, with constant stirring. The food is 
now poured, in quantities varying with the age of the patient, 
in sterilized bottles, properly corked, and placed on ice until 
used. This mixture is indicated especially in cases requiring 
a high percentage of protein and a low percentage of fat, e.g., indigestion. 
gastroenteritis and fat indigestion. 

Proprietary Milk Modifiers and Milk Foods. — We distin- 
guish two kinds of proprietary foods — milk modifiers, and so- 
called milk foods. Neither of them contains a sufficient amount 
of nutrient elements to supply the needs of the baby for life 
and growth for any length of time ; they are useful, however, 
in digestive disturbances and "milk idiosyncrasv," and to in miik 

, .J ^ . r • 1 -pi " ^-1 -11 idiosyncrasy. 

bridge over an acute siege oi sickness, ine mercantile milk 
modifiers furnish soluble carbohydrates, free starch, or pre- 
digested proteids in small quantities, and thus save the trouble 
of home-preparation of suitable diluents. Contrary to what is 
generally expected, the so-called milk foods occasionally prove 
very beneficial in cases of pedatrophy. On the other hand, it 
should be remembered that their prolonged use is frequently 
followed by scurvy and rickets. 

Peptonized Milk. — The use of peptonized milk is nowadays 
limited chiefly to feeding of children of A'ery low vitality, in in very 
whom the powers of digestion are in abeyance, e.g., high fever, digestion. 
coma (administered in the form of nutrient enemata, or by 
gavage), pyloric stenosis, etc. 

Mode of Preparation. — Mix in a quart bottle one pint of 
fresh milk with four ounces of cold water containing 5 grains 
of pancreatic extract and 15 grains of sodium bicarbonate, or 
the contents of one of Fairchild's peptonizing tubes. Place 
the bottle in a pot of hot water and maintain its temperature 
at about 115° F., either for about twenty minutes ("partial" 



80 PREVENTION AND CONTROL OF DISEASE. 

peptonization) or two hours ("complete" peptonization). 
Shake the bottle from time to time. When the mixture is 
ready, give it, either pure or diluted, in quantities suitable for 
the age of the child. Keep it on ice until used. 

WEANING OF THE BABY AND ITS FEEDING 
THEREAFTER. 

Ordinarily it is not advisable to nurse an infant beyond ten 

or eleven months old. As exceptions to this rule, we may 

mention the very hot summer months, acute diseases, difficult 

teething, etc., when a complete change in feeding is prone to 

Time for prove hazardous to the child's health. It is preferable to wean 

■weanmg. ^ ^ 

2L baby gradually, by substituting bottle- for breast-feedings, 
and to continue to partially nurse it, until the infant has 
learned to submit to the inevitable, and thrives well on the 
new food. 

Feeding of Infants Over Ten Months Old. — When the 
normal infant reaches the age of ten months or thereabouts, 
nature announces the urgency of a change in the dietary — from 
liquid to solid — by hastening the eruption of the lower and 
upper incisors which for months had threatened to escape from 
their seat of birth and captivity. At this age also salivary 
transitkm digcstiou is fully established, so that an allowance, once or 
^^*t?other twice a day, of a crust of stale or toasted bread, or zwieback, 
^^*^^^^S)? certainly can do no harm. As at this period of life the tend- 
ency to rickets is very pronounced, the dietary should be grad- 
iially improved upon by the addition of cereals, a teaspoonful 
or more of fresh soft-boiled egg, oatmeal or graham crackers; 
strained chicken, mutton or beef soup, with fresh vegetables 
{e.g., carrots, potatoes, etc.), orange- or pineapple-juice, and 
later baked apple, baked potato with some sweet cream or 
butter, bread and butter, milk custards, cocoa and occasionally 
finely scraped beef or chicken. 

Of course, the transition from an exclusive milk diet to a 
more or less mixed diet must be very slow and gradual. 
The effect of the change should be watched from day to day 
and week to week, always bearing in mind that milk is the 
ideal food for the infant and indispensable to the child up to the 
period of second dentition. 

This fact should be strongly impressed upon those in charge 
of the child, as only too often, with the allowance of a semi- 



XUTRITIOX. 81 

solid diet milk is crowded out entirely by an oversupply of 
thin soups, indigestible, proprietary ''breakfast foods," and all 
sorts of sweets and fruit of poor quality, which sooner or later 
upset the child's digestive powers and arrest its growth and 
development — doing just the opposite of w^hat the change of 
diet was intended for. 

AVith the change in the diet also it is frequently observed Miikto 
that the infants refuse to drink milk. Inquiry into the cause prSicipai ^ 
usually reveals the fact that upon the advice of some artistic- 
ally inclined neighbor — who thinks that the bottle eftaces the 
child's "beauty lines" — and more generally upon the recom- 
mendation of the family physician, the child is forced to part 
with its bottle and nipple — its dear and faithful companions 
for the many months past. A\'hy milk-bottles are to be looked 
upon as an abomination for children oi'er a year or so and as a 
salvation for those under this age, is to me a mystery. The 
mere facts that if given in a bottle, large quantities of milk are Advantages 
enjoyed by children up to four or five years of age; that if miik 
taken through a nipple, milk enters the stomach slowly, and, a bottle, 
hence, is more easily digested, and, finally, that during sickness 
milk (as well as water) is best administered through a bottle, 
are ample justifications for the encouragement rather than the 
prohibition of the use of the bottle — provided, of course, that 
the bottles, as well as the nipples, are kept scrupulously clean; 
are sterilized, if you please. 

The additional articles of food should be given at definite 
intervals, preferably together with the milk feeding. Thus, for 
example, with the ten o'clock bottle the child should receive 
the soft-boiled or poached tgg and crackers ; at two o'clock the 
meat broth and potato; at six o'clock, some cereal and bread 
and butter. Orange- or pineapple-juice may also be given 
between meals. The child should be taught to appreciate that 
to get other food-stuffs it must drink its allowance of milk. 

Feeding of Children of from Two to Four Years Old. — 
With completion of primary dentition, which usually occurs 
between the twenty-fourth and thirtieth months, the dietary of 
the child can be considerably enlarged. The breakfast in addi- Breakfast. 
tion to the milk should consist of well-cooked cereal gruel, 
toasted bread and butter, scraped or baked apple. The dinner Dinner. 
may embrace meat broths, broiled rare steak, mutton chop or 
white meat of chicken — all cut up finely; scraped raw beef, 

6 



82 PREVENTION AND CONTROL OF DISEASE. 

boiled fish ; small quantities of vegetables, such as potato, 
fresh string beans or peas, spinach or asparagus tops, stewed 
Supper, fj-^ji- Qj- ^ little custard or pudding. The supper should include 
a soft-boiled or poached egg, bread and butter, stewed fruit, 
and milk or cocoa. The child should receive a cup of milk 
between breakfast and dinner and between dinner and supper. 
Fresh, pure water should be given between meals, the first 
thing in the morning and the last thing at night. 

Feeding of Children from Four to Six Years Old. — The 
dietary of children over four years old is practically identical 
with that just mentioned, except that the quantity of the food 
liSli should be more liberal, the fruit may be given raw, and that 
^^^^- the between-meals milk allowance should be dispensed with. 
Occasionally the child may receive home-made cake, a little 
ice cream and other condiments of good quality. All these 
food-stuffs, however, should be given with regular meals. 

II. HYGIENE AND SANITATION. 

Next to suitable nutrition hygiene and sanitation play the 
most important role in the preservation of good health. It is 
within the province of the physician's duties to formulate, to 
those intrusted with the care of the child, rules and regulations 
as to its cleanliness and comfort, mode of clothing, time for 
sleeping, airing, bathing, rest and exercise, both during health 
and disease. Without the advice and supervision of the physi- 
cian, the nurse or mother is only too apt to either overdo or 
underdo, i.e., in both events do irreparable damage to the 
health and welfare of the child. The period of blind credulity, 
stupid mysticism and absurd fatalism still reigns supreme, the 
great strides in science and adventure notwithstanding. 

GENERAL CARE OF THE NEWLY BORN AND 
OLDER CHILDREN. 

The Newly Born Baby. — Immediately after birth the infant 
instinctively, by its shrill cry, announces its demand for protec- 
tion against the sharp change of atmosphere and surroundings. 
^S^navJi Therefore, after dressing its navel (see page 173), washing 
and eyes, -^.g ^y^g ^^^ mouth with a Saturated boric acid solution, i the 
baby should be wrapped in a warm woolen blanket and placed 



1 Where gonorrhea in the mother is suspected, we should instill into 
each eye one drop of a 2 per cent, solution of nitrate of silver. 



HYGIENE AXD SANITATION. 83 

in a warm, darkened, but airy, quiet room, and left to rest for ^^^*- 
a few hours. It should then be sponged off with warm soap 
water, dressed, given a little clean water, and, the condition of 
the mother permitting, put to the breast (see page 62). Nursing. 
Wherever possible, the child's crib should be kept in a room 
apart from that of the mother, so that the latter is not dis- 
turbed by the possible uneasiness experienced by the baby. 
As lactation is usually not fully established before the third or 
fourth day after labor, the infant should, in the mean time, 
several times daily receive a few teaspoonfuls of plain or 
slightly sweetened warm water or of a mild carminative, such 
as fennel-seed tea, to satisfy its thirst and hunger. 

Sleep. — The normal newly born baby sleeps practically all 
the time except the brief periods occupied with nursing, diaper- 
ing, and dressing. If the baby is well developed and strong, 
it should be left to sleep until it wakes up of its own accord 
from huno-er: if delicate it should be aroused everv two hours Hours 

^ ' "of sleep. 

during the day, and once at night, made to cry a little to help 
expanding its lungs and put to the breast for from ten to 
twenty minutes. At six weeks the infant needs twenty hours 
of sleep ; at three months eighteen ; at one year sixteen and 
from tAvo to four years fourteen hours of sleep. All children 
should get accustomed to sleep uninterruptedly (except for one 
nursing in the middle of the night in early infancy), from seven 
in the evening until seven o'clock in the morning, and one hour 
each sometime between seven and twelve o'clock in the fore- 
noon and two and seven in the afternoon. 

Sleeplessness in the infant is ordinarily due to intestinal 
colic or other pain, discomfort from soiled diapers or faulty 
dressing (overheating by superabundance of clothes, etc.), 
noise in the room, lack of A^entilation, bad habits, such as rock- 
ing, or keeping an empty nipple in the mouth, etc. Repeated 
waking is frequently due to over- or under-feeding. 

Bathing. — In view of possible local or systemic infection 
(see page 172) through the umbilical rest, and the advis- 
ability of keeping the latter perfectly dry, the full tub-bath 
should be withheld until the navel has completely healed. The fo^e""^ 
same applies for circumcision wounds. In the mean time the postponed, 
infant should receive at least one sponge bath a day, to be 
given as gently as possible, since the infantile skin is very 



84 PREVENTION AND CONTROL OF DISEASE. 

delicate, very apt to be abraded on rough handling, and readily 
becomes subject to divers skin affections. 

In the absence of the aforementioned or other contraindica- 
tions, every child, in addition to local cleansing as frequently 
as necessity arises, should receive a tub-bath once a day, prefer- 

bath-witS! ^^^y ^^ bedtime. The water used should be free from visible 
impurities, and obtained from sources inaccessible to pollution. 
The temperature of the water should range between 95° F. and 
98° F., the latter for infants under six months, and cooler water 
for older ones. Fat babies tolerate much lower temperatures, 
but I see no special benefit to be derived from the use of bath- 
water under 95° F. unless it be in the open sea or ocean (which 

Temperature is permissible in children over three years of agfe), where the 

of the T . . o / ' 

water, saline ingredients and forceful current exert a stimulating, 
refreshing effect upon the system and thus counteract the 
depression produced by the sudden lowering of the body tem- 
perature. If cool bathing is desirable it is better to place the 
child in warm water and either to gradually cool off the water 
while the child is in the tub or use a cold shower. The bath 
should be followed by thorough drying of the body and gentle 
friction. Care should be exercised in the selection of pure, 
non-irritating bathing soap, lest its irritating ingredients may 
oArriutTon P^'o^e a sourcc of anuoyiug skin eruptions. For the same 
of the skin, reason and, furthermore, owing to the fact that they are apt 
to harbor dirt and disease, the use of sponges is to be 
deprecated. 

Clothing. — Infants should be clothed warmly and simply, 
free from fancy frocks and frills, strings and bows, that embar- 
rass free motion, breathing, sleeping and eating. The under- 
siikor wear should be made of silk or thin flannel. The abdomen 
underwear, should be protected against being chilled by a flannel band. 
The consistency of the outer clothing should vary with the 
changes of the weather and season of the year. The feet 
of infants should at all times be kept warm, if necessary, by 
means of a hot-water bag. The night clothes should be loose 
and warm, and consist, in addition to a small silk or flannel 
shirt. Canton flannel or stockinet diaper and the belly-band, of 
^bag^ a nightshirt in the form of a "bag" that buttons around the 
neck and can be closed at the feet by means of drawstrings. 
In this manner the unnecessary piling up of blankets, to keep 
the baby from uncovering, can advantageously be dispensed 
with. 



HYGIEXE AXD SANITATION, 



Older children should gradually get accustomed to light 
clothes — linen or silk undergarment, linen or woolen suit or 
dress, and for the winter a warm top coat and cap — but no 
collars or neck mufflers. A Avoolen union suit with feet for the 
night. Especial attention should be paid to the selection of 
shoes. They should comfortably fit the feet and allow spread- 
ing of the toes. The stockings should be fastened to the 
drawers, as garters are apt to interfere with the blood circula- 
tion of the lower extremities. The corset should be prohibited 
in girls under fourteen. 

Airing. — Fresh, pure air is the panacea for good health, the 
cure of all bodily ills. Thus far it is non-assessable, non-tax- 
able, and hence should be inhaled ad libitum — while this free- 
dom lasts. Weather permitting it should be inhaled out of 
doors, otherwise indoors — in properly ventilated rooms. The 
newl}^ born baby should be taken out of doors in the summer 
when it is two weeks old, in the spring and fall at one month 
and in the winter at two months of age or later. It should be 
suitably dressed and protected from undue exposure to the sun 
and wind and severe cold. It is foolhardy to expose an infant 
to marked atmospheric changes without proper shelter, merely 
for the purpose of "hardening" it. Its first airing should last 
from fifteen to thirty minutes, and as it grows older the airing 
time should be lengthened so that, weather permitting, the 
child may live out of doors the greater part of the day from 
sunrise until sunset. Slight rain or snow forms no hindrance 
to taking the baby out of doors, although in such weather 
delicate babies do better if aired indoors, in front of open 
windows and dressed as for outdoors. 

Exercise. — A healthy infant, if not immobilized by burden- 
some clothes, begins to take physical exercise soon after birth. 
It kicks, moves its arms and head and exercises its thoracic 
muscles while crying lustily, especially when feeding time 
approaches. It should be picked up in the arms at every nurs- 

:\t about four months of 
it may then be 

gradually trained to sit upright upon the arm of the nurse with 
the hand of the other side supporting its back and head. As 
it reaches the age of seven or eight months, the infant may be 
seated aloiie in a baby-chair supported with pillows at the 
back and sides. When it shows an effort to creep, it may be 



ing to insure change of position. 

age the baby is able to hold its head erect 



Shoes to 
fit the 
feet. 



Fresh air 
at all times; 
outdoor air 
only when 
weather 
permits. 



Frequent 
change of 
position. 



Holding 
head erect. 



Sitting 

and 

creeping. 



86 PREVENTION AND CONTROL OF DISEASE. 

placed upon the floor, which should be well covered by thick 
carpet or a blanket, preferably within a small portable "creep- 
ing pen/'' and allowed to roam about for half an hour at a time 
once or twice a day. Less freedom should be granted an 
^^^^^and infant in its first attempts to stand or walk. These practices 
walking, should not be encouraged in babies under one year of age, nor 
in older children who show a tendency to bony curvatures and 
rickets. In the beginning they should not be allowed to 
stand or walk, especially if unsupported, for more than a few 
minutes at a time. But, as they grow older and stronger they 
are gradually permitted to enjoy shorter or longer outdoor 
walks and to romp merrily, giving vent to that characteristic 
boundless joyousness of early childhood which is blessedly 
ignorant of the pangs and pains of later life. 

Older children, like infants, should spend the greater por- 
tion of the day outdoors in parks and play-grounds and engage 
in amusing games and light calisthenics which will keep them 
from harm and mischief. It is opportune on this occasion to 
Danger of emphasize the danger of overindulgence in the practice of 
indulgence gymuastics, especially in children of school age — a period of 
life which is coincident with prevalence of communicable dis- 
eases and their grave sequelae, particularly cardiac involvement. 
Carried away by the enthusiasm over the daring feats of the 
author and exponent of ''strenuous life," the young and old 
alike have recently rushed for rough athleticism with a ven- 
geance, that is daily reflected by multitudes of crippled, so- 
called athletic, hearts, and apt to become a menace to the 
health and welfare of our country. 

It is the duty of the ph3^sician to impress upon those under 
Value of his care that while moderate exercise, especially walking, 
™xer^cise^ skatiug and horse-back riding; the daily use, for about fifteen 
minutes at a time, of light wooden dumb-bells, light clubs or 
wands; the practice of breathing (see page 353), of swing- 
ing of the body from a swinging bar or rings and straps, will do 
much for the development of delicate and narrow chests and to 
prevent and straighten curvatures of the spine, stooping of the 
shoulders, and the like (and should be encouraged), violent 
sports, like racing, rough baseball- and football-playing, leap- 
ing, prolonged swimming and similar severe exercises indulged 
in to excess, Avill sooner or later lead to cardiac hypertrophy 
with its consequences. 



HYGIENE AND SANITATION. 87 

Nursery. — As infants and older children spend about two- 
thirds or more of their time of life in the nursery, provisions 
must be made that the room is spacious and airy, dry and 
sunny, that its air is fresh and pure, free from obnoxious odors, 
gases, dust and smoke. To thrive well an infant requires Air space, 
about 1000 cubic feet of air space. The room should not be 
crowded with dust gatherers, i.e., overabundance of furniture, 
toys, heavy hangings, carpets, rugs, pictures, etc. The tem- 
perature of the room should be about 70° F. during the day and Temperature, 
about 65° F. during the night. Whenever possible it should 
be heated from an open fire-place or a hot-air furnace. Steam 
heat or gas greatly vitiates the air. To insure proper ventila- ventilation, 
tion, it is advisable to keep the windows more or less open 
from top and bottom most of the time unless the outdoor 
temperature is below 35° F. The windows and doors should 
be widely opened while the child is out of doors, otherwise 
ventilation should be accomplished with the doors closed to 
avoid draughts. For the latter purpose one of the many 
ventilating devices on the market will prove very serviceable. 

Financial circumstances permitting, every child should have 
a separate room, if possible, situated one floor above the 
ground. Of course, this is rarely attainable in the dingy apart- 
ments of overcrowded cities. Physicians should insist, how- 
ever, on every child having a separate bed in order to minimize 
the danger of transmitting communicable diseases from the 
sick to the healthy child. 

The Sick-room. — The hygienic suggestions just made in 
reference to the nursery apply with greater force to the sick- 
room. If possible, the latter should be situated on a different 
floor from the living apartments. From a sanitary as well as 
economic point of view it is essential to have the sick-room gatherers, 
cleared of curtains, tapestries, superfluous furniture, carpets, 
etc., so as to facilitate keeping the room perfectly clean, and to 
prevent pathogenic germs {e.g., with the skin-peeling of scar- 
latina), becoming firmly imbedded in those articles. The floor 
and furniture of the sick-room should be wiped off with a damp 
cloth instead of dusted or swept. 

An ante-room is a useful addition to .a sick-room, especially Ante-room, 
when the patient is suffering from a communicable affection, 
as it enables the nurse to disinfect the dishes, soiled bed-clothes, 
linen, etc., and to prepare some of the patient's food. 



88 PREVENTION AND CONTROL OF DISEASE. 

When the isolation-period of the patient is over, the sick- 
room, ante-room and their contents must undergo very 
thorough cleaning and disinfection. 

Quarantine and Disinfection. — In order to prevent spread- 
ing of communicable diseases from one individual to another, 
we have to resort principally to the following prophylactic 
measures : — 

1. Isolation of the patient. 

2. Disinfection of the patient's excretions, fomites, etc., 
coming in contact with the pathogenic micro-organisms. 

3. Exclusion and destruction of other germ-carriers, e.g., 
mosquitoes, flies and fleas, 

1. Isolation of the Patient. — This is the most essential 
and efficient mode of prevention of transmission of disease. 
The isolation to be effective must begin early and be complete. 
Early and In hospitals and asylums every child should be isolated in an 
isolation, observation ward for at least three days before being permitted 
to mingle with the other inmates; in private families isolation 
should be enforced with the earliest appearance of tangible 
symptoms of the specific aiTection. As those coming in close 
contact with the patient are apt to carry the disease from the 
sick to the well, it is imperative to isolate the nurse together 
with the patient and to forbid any member of the family to 
stay around the sick-room or make herself generally useful 
unless on entering the sick-room she dons a clean gown and cap, 
and before leaving it washes her hands and forearms with soap 
and water and removes the gown and cap. These latter rules 
should be complied with also by the physician. 

In a private dwelling, and especially in houses where a 
room is reserved for the sick, perfect isolation can readily be 
insured. In crowded tenement rooms, however, with people 
in poor circumstances, all attempts at isolation almost invari- 
ably fail, and where the spreading of a grave, epidemic afifec- 
tion is concerned {e.g., small-pox, cerebrospinal meningitis), 
should not at all be attempted. In such cases it is best to 
tohospuTL remove the patient to a hospital for contagious diseases. 

The period of isolation varies, of course, with different dis- 
eases and the degree of severity. The following suggestions 
will meet the ordinary requirements as to the period of isola- 
tion and the principal mode of prophylaxis : — 



HYGIENE AND SANITATION. 89 

In typhoid fever, while the disease lasts. (Disinfection of periods of 
excreta; protection against flies.) indifferent 

In typhus fever, while the disease lasts. (Free ventila- diseases, 
tion.) 

In miliary tuberculosis, while the disease lasts. (Disinfec- 
tion of excreta.) 

In epidemic cerebrospinal meningitis, while the disease 
lasts. (Disinfection of discharges.) 

In yellow fever, while the disease lasts. (Destruction of 
mosquitoes.) 

In relapsing fever, while the disease lasts. (Destruction of 
insects.) 

In influenza, pneumonia and pulmonary tuberculosis, while 
the diseases last. (Disinfection of discharges.) 

In bubonic plague, about one week after termination of the 
disease. (Destruction of vermin, especially rats ; disinfection 
of excreta.) 

In cholera Asiatica and epidemic dysentery, one week after 
termination of the disease. (Disinfection of excreta; avoid- 
ance of pollution of water, milk, etc.) 

In small-pox, six weeks. (Vaccination, disinfection of 
discharges.) 

In chicken-pox, three weeks. (Disinfection of discharges 
and skin.) 

In measles, two weeks. (Disinfection of discharges and 
skin.) 

In German measles, two weeks. (Disinfection of dis- 
charges and skin.) 

In diphtheria, as long as diphtheria bacilli abound in the 
throat. (Disinfection of discharges.) 

In scarlet fever, while the desquamation lasts. (Disinfec- 
tion of discharges and skin.) 

In whooping-cough, while whoop or vomiting lasts. (Dis- 
infection of expectoration.) 

In mumps, three weeks. (Disinfection of sputum.) 

In erysipelas, two weeks. (Disinfection of the skin; anti- 
septic dressing.) 

In gonorrheal ophthalmia or urethritis, while gonococci are 
found in the discharges. 

Before leaving the isolation-room, the patient should receive 
a cleansing-, hot, soap-water bath (including thorough scrub- 



90 PREVENTION AND CONTROL OF DISEASE. 

bing of the scalp, ears, finger- and toe-nails), and dressed anew 
with freshly disinfected clothing. 

2. Disinfection of Excreta^ of Fomites, etc. — In order to 
be on the safe side, the nurse should be instructed to disinfect the 
stools, urine, vomitus, sputum, and nasal, aural, conjunctival 
and vaginal discharges of the patient, regardless of whether or 
not they carry contagious matter. 

For Excreta. — Chloride of lime in powder or in solution. 
Four ounces of lime to one gallon of soft water. A sufficient 
quantity of this solution should be thoroughly mixed with the 
feces, urine, sputum, etc., and allowed to stand for about three 
hours before emptying. 

Sputum is best collected in paper cups or small cloths and 
immediately destroyed by fire. 

Bichloride of mercury in solution 1 : 500 — a 7^-grain tablet 

Disinfecting . .- ^ ,,.,.,_ . 

solutions, m a pmt of water. Copper sulphate m solution (5 per cent.). 
Zinc sulphate in solution (lo per cent.). Cresol or creolin in 
solution (5 per cent.). 

For Clothing, Bedding, Linen, etc. — Destruction by fire — the 
safest measure. Exposure to dry heat at a temperature of 
about 300° F'., or moist heat at 212° F., for two hours. Boiling 
for at least half an hour. Immersion in a bichlorid solution 
(1 : 2000) for about three hours. Fumigation by formaldehyd 
(see below). 

For the Hands, General Body, Dishes, etc. — Labarraque solu- 
tion (chlorinated soda, 10 per cent). Bichlorid of mercury in 
solution (1 : 1000). Permanganate of potash in solution (§j to 
a quart of water). Formaldehyd in solution (1:200). 

For Rooms, Furniture, Mattresses, etc. — Fumigation by For- 
maldehyd Gas. — It may be employed in concentrated powdered 
form or in pastels. For small rooms the ordinary Shering 
Fumigation, lamp, which is constructed for vaporizing formaldehyd pastels, 
will suffice. For large hospital wards, however, the 'Jormal- 
dehyd-potassium-permanganate method" is best. It is of advan- 
tage to use a container consisting of a large open vessel 
protected from losing its heat by some non-conducting 
material such as asbestos. But one can get along almost 
equally as well by using a large milk-pail set in a wooden 
bucket. 

The infected room should be made as air-tight as possible by 
snugly closing the windows and doors (key-holes, ventilators. 



IMMUNIZATION. 



91 



fire-places, etc.) by means of cotton or cloths. All articles 
intended for disinfection are freely exposed (mattresses, pillows, 
boxes and drawers should be opened). 

The fumigating apparatus is placed in the center of the room ; 
GVi ounces of potassium permanganate (for each 1000 cubic feet 

^^ ^ . ^ . , Formaldehyd 

of room space) are put m the contamer ; and 16 ounces of 40 per potassium 

perman- 

cent. formaldehyd solution (for each 1000 cubic feet of room ganate. 
space) are poured on the top of the permanganate. The operator 
now quickly leaves the room, and closes the door or window. 
The room should remain tightly closed for about ten hours. 

After disinfection the disagreeable odor of the formaldehyd 
may be removed by sprinkling the room with ammonia water, 
and thorough ventilation. 

Fumigation with Sulplnir. — The procedures are the same as suiphur. 
with formaldehyd. The sulphur, about three pounds for a room 
10 feet square, is placed in an iron pan, supported by bricks and 
set in a tin vessel with water. The sulphur is ignited by live 
coals or a tablespoonful of alcohol lighted by a match. Sulphur 
fumigation should not wholly be depended upon after grave 
epidemic affections. 

Finally, it is well to bear in mind that sunlight is a disin- sunlight, 
fectant of great efficiency, and that prolonged exposure to its 
rays will materially aid in rendering rooms and fomites free from 
infectious matter. 



III. IMMUNIZATION— ACQUIRED IMMUNITY. 
LOGIC DIAGNOSIS AND THERAPEUTICS. 



BIO" 



Medicine is rapidly reaching the goal of its highest ambition, 
the prevention and control of communicable diseases by ''Nature's 
method," i.e., immunization (see page 60). Stupid skepticism 
and boundless enthusiasm are gradually yielding to deliberate 
experimentation and experience, and it does not require a very 
g-reat stretch of imasfination to predict that in the near future sense soon 

^ ... .to reign 

every communicable affection will be successfully resisted and supreme, 
combated by an antagonist evolved by the causal micro- 
organism. 

In order to obviate unnecessary repetition we will briefly 
describe the biologic products at present in use for diagnostic, 
protective and therapeutic purposes and the results thus far 
achieved. " c 



92 PREVENTION AND CONTROL OF DISEASE. 

VARIOLA VACCINE. 

With the enforcement of vaccination by all civilized nations 
small-pox, the most loathsome pestilence, has practically been 
eradicated from every well-regulated community. The principle 
of vaccination is the introduction into the human body of a 
Vaccinia, weakened and harmless form of vaccinia, cow-pox, which 
renders the system immune (i.e., creates enough of antibodies 
to resist the disease) to variola. The vaccine is obtained from 
the vesicles that form on healthy young heifers as a result of 
inoculation with the virus of cow-pox. 

VACCINATION. 

In the absence of contraindications (see page 94) every child 
of from 6 to 12 months old should be vaccinated, and revac- 
cinated about seven years later. It is preferable to vaccinate 
at a time when neither excessive heat nor cold prevails, i.e., in 
May or October. The right arm at the insertion of the deltoid is 
usually chosen for the first vaccination, and the left for revac- 
cination. In girls the leg may be preferred to avoid the 
possibility of an exposed disfiguring scar. The parts to be 
inoculated should be freely bared and cleansed with soap- 
precautfons! watcr and thoroughly dried. When one inoculation is to be 
made the epidermis should be abraded for about an eighth of an 
inch in diameter (until a serous exudate or a trace of blood 
occurs) by means of a sterile needle; when several inocula- 
tions are to be made, they should be fully one and a half inches 
apart. About a drop of vaccine is then gently rubbed into the 
denuded surface and allowed to dry. In successful vaccina- 
tion the inoculated area begins to redden and swell on the 
Signs of third or fourth day; on the fifth day a vesicle appears which 

SUCCGSSf Ul 

vaccination, gradually changes into an umbilicated pustule surrounded by 
a red areola. The pustule persists up to the eleventh or 
thirteenth day and then becomes covered by a scab. The 
latter remains stationary about ten days longer, then falls olT, 
leaving behind a red scar which gradually becomes white and 
glistening in appearance. The scar usually remains visible 
throughout life. Vaccination is associated with more or less 
marked constitutional symptoms. With appearance of the vesicle 
there is a slight rise of temperature ; the child is restless, sleeps 
badly, loses its appetite, and shows other signs of indisposition. 



IMMUXIZATIOX. 93 

Some children react more strongly than others, but if the vaccine 
is pure, the vaccinator clean and careful and the inoculated area 
kept free from irritation and infection, all the constitutional 
symptoms disappear by the twelfth day. Under adverse circum- sepsis. 
stances {e.g., old, impure lymph, defective asepsis, constitutional 
diseases) vaccination may be accompanied by very grave symp- 
toms. The pustules may become very large ; the redness in the 
vicinity very marked and extensive ; the axillary glands very 
much swollen and painful; the whole arm very strongly infil- 
trated ; the fever very high, up to 104° F. ; and convulsions and 
respiratory and gastrointestinal symptoms develop. Suppuration 
of the glands, phlegmonous processes, and even erysipelas may 
set in. Finally, vaccination may be accompanied by transient or 
genuine nephritis, and cases of scrofula, tuberculosis and syphilis onltent'^^ 
are on record — undoubtedly pre-existent, latent, but awakened by or sy^pMUs!^' 
the acute inflammatory process. Occasionall}' the inoculation 
wound fails to cicatrize, continues to suppurate or ulcerates. 
Children with a tendency to skin diseases may develop divers skin 
eruptions, such as erythema, eczema, lichen, impetigo, psoriasis, 
a purpura-like eruption (purpura vaccinatoria) , general furun- 
culosis. or, bv transference (autoinoculation) of the vaccine 

' . 1 - . , . , , . . General 

Virus to some diseased parts ot the skm, produce general vaccinia, vaccinia. 

(The latter may develop — usually about the seventh or eighth 

day — spontaneously, from within, independently of any external 

influences. The lesions, which may be discrete or confluent 

(grave), bear a certain resemblance to the regular vaccinal 

pox.) In the same manner the vaccine may be carried to the 

eyes (vaccine ophtJiahnia) , and cause serious trouble. In fact, 

inoculation pustules have been observed on different portions 

of the bodv, and even on the tonsfue. Furthermore, vaccinia 

... J Auto- 
may also be transmitted to other persons by means o± mtected inoculation. 

articles in use, fingers, bed-sheets, bath-water, sponges, etc. 
Hence the importance of a protective dressing over the vac- 
cination mark (clean sterilized linen, sewn to the sleeve, 
changed every day) from the time the vaccine has dried up 
to the falling off of the scab, and of keeping the child's nails 
very short and its hands very clean. Bathing should be inter- 
rupted from the fifth to fifteenth day. Moist boric acid dress- 
ings are useful to reduce the severe, local inflammatory process, 
and where the latter is srrave, and the itchinsf intense, a con- ^.. 

. . . . Nitrate 

tinuous, moist dressing with nitrate of silver (V4 per cent.) of silver. 



94 PREVENTION AND CONTROL OF DISEASE. 

will prove especially beneficial. In delayed healing the wound 
should be cauterized with a 5 per cent, to 10 per cent, solution 
of nitrate of silver, and dressed like any other wound. Other 
complications arising should be treated according to indica- 
tions. 

Revaccination. — As already suggested revaccination should 
be performed about seven years after the first vaccination, a 
period of time after which the immunity against small-pox 
To guard usually ceases. In case of epidemics revaccination should be 
epidemS. resortcd to more frequently. Revaccination is also indicated to 
modify an attack of small-pox. In successful revaccination the 
local and systemic manifestations are essentially the same as 
after the first vaccination except that they are much milder in 
form. 

Contraindications to Vaccination. — It is not advisable to 
vaccinate infants under three months, and children of all ages 
who are suffering from severe acute and recurrent skin affections, 
local or general syphilitic or tuberculous (scrofular) lesions and 
great debility. 

ANTIDIPHTHERITIC SERUM. 

Diphtheria antitoxin is the purified blood-serum of a horse 
that has been rendered immune to diphtheria by a long course of 
treatment with diphtheria toxin. It is specific in its effects, having 
mortality, lowered the high (40 to 60 per cent.) mortality from diphtheria 
to about 5 per cent. — if administered early and in ample quan- 
tity. Furthermore, those exposed to diphtheria almost invariably 
escape infection by timely administration of the serum. It is 
practically harmless if free from admixture of virulent bacteria, 
and with introduction of the concentrated, high-grade prepara- 
tions and the application of greater care in handling and adminis- 
tration, the numerous disagreeable accompaniments (fever, 
multifarious eruptions, articular swellings, etc.) have ceased 
to be as common and as severe as in former years. 

The dose of antitoxin for ordinary cases of diphtheria should 
Dosage, be 1000 units for every year of the child's age up to six years, 
to be repeated once or twice at intervals of from six to twelve 
hours. Malignant, especially laryngeal, cases require double 
doses. For protective purposes a third of the ordinary dose 
usually suffices. The protection usually lasts from four to six 
weeks. 



IMMUNIZATION. 95 

The antitoxin is administered by a sterile hypodermic syringe 
(or the mercantile serum-containing syringes) by deep injection 
into the anterior surface of the abdomen or thorax or outer sur- precautions, 
face of the thigh, which are rendered aseptic by soap-water, ether 
and alcohol. The point of injection is subsequently sealed by 
sterile adhesive plaster. 

ANTITETANIC SERUM. 

Like diphtheria antitoxin, antitetanic serum is obtained from 
the blood of horses previously immunized to the toxin of the 
tetanus bacillus. Its efficacy as a curative remedy is as yet await- 
ing indisputable demonstration, but its value as a preventive of 
tetanus is authoritatively established. Whenever there is reason 
to fear tetanus infection {e.g., contused or lacerated wounds — 
toy-pistol wounds — soiled with earth or other foreign matter) 
especially when an unusually large number of tetanus cases 
prevail, it is imperative promptly to administer tetanus antitoxin 
as a prophylactic measure. 

Tetanus antitoxin is usually administered subcutaneously in Dosage, 
doses of 1000 to 1500 units; the dose is repeated as a preventive 
measure after ten days, as a curative (3000 to 15,000 units) 
several times a day. In urgent cases the antitoxin may be 
given by intravenous, intracerebral or subarachnoid injection. 

ANTIMENINGITIS SERUM (FLEXNER). 

This serum acts specifically in cerebrospinal meningitis due 
to the diplococcus intracellularis (Weichselbaum) only. If used 
by the subdural method of injection in suitable doses, promptly 
and 'at proper intervals, it is capable of greatly diminishing the 
fatality generally due to the disease; of reducing the period of 
illness, and, in a large measure, of preventing the chronic 
lesions and types of the affection. 

After reducing the intracerebrospinal pressure by with- 
drawal, by lumbar puncture (see page 339), of about 30 to 60 
cubic centimeters of cerebrospinal fluid, we inject 30 cubic Dosage, 
centimeters of the serum into the spinal canal by means of an 
antitoxin syringe or by gravity through a funnel and rubber tube 
attached to the puncture needle. The injection is repeated 
daily for three or foiir days or longer until the diplococci dis- 
appear. In fulminating cases a second dose may be given 
after the lapse of twelve hours. If after a period of apparent 



Opsonic 



96 PREVENTION AND CONTROL OF DISEASE. 

recovery the symptoms recur and the diplococci reappear, the 
injection should be repeated. The serum is practically useless 
in cerebrospinal meningitis after the condition of hydro- 
cephalus has supervened. 

Several other sera {e.g., antipneumococcic, antidysenteric) 
are now on the market. Their curative merits, however, are 
still unestablished. 

BACTERIAL VACCINES. 

Following upon the great researches of our contemporary 
pathologists, bacteriologists and clinicians, A. E. Wright, of 
London, has demonstrated the remarkable fact that emulsions of 
dead bacteria — bacterial vaccines so called — if injected subcu- 
taneously increase chemotaxis and, therefore, phagocytosis. The 
molecular group produced by the presence of the killed bacteria 
in the blood that renders the living bacteria of the same species a 
ready prey to the phagocytes he designated ''opsonin," correspond- 
index. ^^g to the Greek verb "opsono" — I cater for, I prepare victuals 
for. He also devised a method to determine the ''opsonic index," 
or sensitizing power of the blood, so that in a given case of 
infection one can, as it were, measure the opsonin content of the 
blood and increase it, if found below par. 

Bacterial vaccine therapy is as yet limited to local infections, 
e.g., furunculosis, phlegmons, carbuncles, where the ofifending 
micro-organisms can readily be determined by microscopic exami- 
nation of the discharges, and accordingly the vaccine chosen to 
meet the indications. 

Of the numerous vaccines thus far recommended the staphy- 
lococcus and streptococcus vaccines have actually stood the test 
staphyio- and proved of great utility. They are deserving of more general 
vaccines, application. 

Favorable results are also on record from the use of vac- 
cines prepared from the bacillus coli (in colicystitis) ; from 
gonococci (in gonorrheal affections, especially vulvovagini- 
tis) ; from typhoid bacilli (in typhoid, especially as a preventive 
measure). 

The inoculations are given by means of a sterile hypodermic 
syringe, in the same manner as antitoxin. In children particularly 
Dosage, it is advisable to begin with small doses, let us say, 50 million 
staphylococci, or 2 million streptococci, and to increase the dose 
at each succeeding injection, which should occur every three to 
seven days. 



Strepto- and 



IMMUNIZATION. 97 

In order to obtain prompt results it is essential to know not 
only the specific infecting micro-organism but also its variety, 
for instance, whether the offending staphylococcus is an aureus, 
albus, or citreus, as the employment of a different variety of 
vaccine is apt to prove useless. 

Bacterial vaccines are often prepared directly from cul- 
tures obtained from the individual to be treated. 

TUBERCULINS. 

These bacterial products are invaluable in the early diagnosis 
of tuberculosis in children. By means of tuberculin we are 
enabled to detect from 90 to 95 per cent, of cases of tuberculosis, 
often at a time when no other clinical manifestations or bacterio- 
logic examinations indicate its presence. It has furthermore specific 
the great advantage that its use calls for no complicated pro- tests. 
cedures, methods, calculations or instruments. The specific test 
is based upon the fact that on meeting with the antibodies evolved 
by the organism the tuberculin sets up a reaction, which is mani- 
fested either by a local inflammation or systemic disturbance. 

The tuberculin reaction may be elicited in the following 
manner : — • 

1. The Cutaneous Method (von Pirquet). — After cleansing 
the anterior surface of the forearm with soap-water and ether, 
two small abrasions (as for vaccination) or punctures of the 
skin are made at an interspace of about two inches. On one of 

the two abraded spots a drop of a 50 to 100 per cent, solution papule, 
of Tb is applied and allowed to dry. If tuberculosis is present, 
a red pea- to bean-sized papule appears after from twenty- 
four to forty-eight hours at the point of contact of the injured 
skin and tuberculin, while the other non-tuberculized spot remains 
free from the inflammatory reaction. 

2. Conjunctival Method (Calmette). — A drop of >^ to 1 per 
cent, (trying the weaker solution first) of old Tb solution is 
instilled into the conjunctival sac of one eye. In the presence 

of tuberculosis a positive reaction is manifested within twenty- congestion, 
four hours by reddening of the caruncles and semilunar fold of 
the conjunctiva and injection of the corneal conjunctiva. The 
other eye remains normal. 

3. Nasal Method (Wolff-Eisner and Calmette).— A cotton 
tampon saturated with a 1 per cent, solution is applied against 
the nasal septum and allowed to remain there for about ten 



98 



PREVENTION AND CONTROL OF DISEASE. 



Yellow 
crust. 



Papules. 



method is less 
A 50 per cent, 
square inch of 
papules 



minutes. In from eighteen to forty-eight hours a peculiar exuda- 
tion appears which dries and forms a yellow crust upon a con- 
gested mucosa. From this clumps of extravasated red cells pro- 
ject here and there as minute reddish points. The crust generally 
falls off from the fourth to the sixth day. 

4. Percutaneous Method (Moro). — This 
reliable than the aforementioned procedures, 
tuberculin ointment is rubbed over about a 
epidermis until absorbed. If the reaction is positive 
appear within from twenty-four to forty-eight hours. 

5. Subcutaneous Method. — Almost never employed in 
young children. 

Tuberculin-therapy. — A very enthusiastic revival has 
recently taken place in the employment of tuberculin in the 
treatment of tuberculosis, especially of bones, joints, glands 
and the skin. As during the period of the tuberculin treat- 
ment the patients are receiving also the benefits of outdoor 
aiir, good food, tonics, etc., it is still questionable whether the 
results warrant the unbounded enthusiasm. However, the 
administration of tuberculin in m.inute, gradually increasing 
doses (%o i^§"v %o ^g-, %o g^-, 1 mg., etc., every three days, 
up to 1 eg. or more^ — subcutaneously into the cellular tissues 
of the thorax) being harmless, there is no objection to its use 
in selected cases. 



Mode of 
preparation. 



SERUM DIAGNOSIS OF SYPHILIS (WASSERMANN).2 

The substances employed in this reaction are as follows^ : — 
1. Fresh Serum of the Guinea-pig. — The animal is bled 
from the carotid or the femoral artery. The blood thus obtained 
is either rapidly centrifuged or allowed to stand for some time 
after first removing the upper layer of the clot which adheres to 
the walls of the receptacle. The separated serum floating over 
the clot is drawn oft' by means of a pipette with a rubber tube 
and glass mouthpiece attachments. The serum should be kept 



1 Centralbl. f. Kinderheilkunde, May, 1910. 

2 In view of its comparative simplicity, the technique perfected by 
Dr. J. Bauer, of Diisseldorf (La tribune med.), is here described. 

3 Noguchi employs for Wassermann's reaction small squares of 
paper representing measured amounts of the antigen, amboceptor, and 
the complement, thus greatly simplifying the method and enabling the 
physician to perform the test in his office, provided he can procure 
active Noguchi test-papers. 



IMMUNIZATION. 99 

on ice ready for use, and before using diluted with ten parts of 
salt solution. 

2. Washed Sheep's Blood-corpuscles. — This is a 5 per cent, 
suspension. The blood is collected from the jugular vein of a 
sheep in a sterile bottle containing iron filings, to avoid coagula- 
tion, and is shaken for ten minutes. It is then strained through a 
sieve to remove the fibrin and centrifuged and washed with salt 
solution. This is repeated several times until the solution over 
the sediment remains quite clear. The liquid is then poured oft* 
and an equal (the same as it was after the first straining) quan- 
tity of normal salt solution is added instead, so that the propor- 
tion of the blood-corpuscles remains the same. From this sus- 
pension we prepare a 5 per cent, solution (by adding to one part 
of the blood mixture twenty parts of physiologic salt solution) 
and place it on ice ready for use. 

3. Normal Human Serum. — This is obtained preferably 
from the blood of a placenta. The serum should be heated over 
a water bath up to about 130° F. to render it inactive. 

4. The Syphilitic Extract. — This is prepared by triturating 
in a mortar 100 cubic centimeters of alcohol (96 per cent.) and 
10 grammes of the liver of a syphilitic infant, allowing it to stand 
(well covered) over night, centrifuging, decanting the clear liquid 
and placing it on ice. 

With the mother solution of the organic extract ready, we 
now proceed with an experimental test as follows: Into a series 
of test-tubes we pour, respectively, 0.25, 0.15, 0.10, 0.05, 0.025 
and 0.015 cubic centimeter of the mother solution of liver 
extract, and to each of the tubes we add enough of physiologic 
salt solution to make its total content equal 1 cubic centimeter. 
In addition another test-tube (control tube) is filled with 1 cubic 
centimeter of salt solution without any organic extract. In each 
of the six tubes containing the extract we next pour 1 cubic 
centimeter of the fresh 10 per cent, solution of guinea-pig's 
serum, then 0.2 cubic centimeter of normal human serum heated 
up to about 130° F. The series of tubes is next placed in an 
incubator at 99° F. for thirty minutes, then each tube charged 
with 1 cubic centimeter of a 5 per cent, of sheep's blood-cells. 
and again put into the incubator for two hours. If now the con- 
tents of all the tubes (except, of course, the control-tube, in 
which the liquid should always be clear) are found dissolved, 
the first tube can be used, otherwise any of the remaining 



Experimental 
test. 



Actual 



100 PREVENTION AND CONTROL OF DISEASE. 

tubes in which the solution is complete. As each tube con- 
tains 1 cubic centimeter of fluid and indicates the amount of 
organic extract therein^ we can readily tell how much of the 
latter is required for the diagnosis. Suppose, for example, 
that in the experiment the fourth tube be selected as perfectly 
dissolved, we at once know that the quantity of organic 
extract needed for the test is 1 in 20. The correctness of the 
conclusion should be verified by repeating the test with differ- 
ent dilutions of the extract (1 : 10, 1 : 20, 1 : 30, etc) and several 
specimens of blood of healthy and positively syphilitic 
persons. 

5. The Serum of the Patient. — The serum is obtained by 
puncturing a subcutaneous vein or finger with a large needle and 
collecting it in a test-tube. Allow it to clot ; remove the separated 
serum ; centrifuge to clearness ; pipette off into another test-tube, 
and render it inactive by an half-hour's exposure to 130° F. 

Now that everything is ready for the actual test, we fill four 
test, test-tubes as follows : — 

Tube 1. 

The patient's serum 0.2 c.c. 

The organic extract (tested) 1.0 c.c. 

The guinea-pig's serum (1 :10) 1.0 c.c. 

Tube 2. 

The patient's serum 0.2 c.c. 

Physiologic salt solution 1.0 c.c. 

Guinea-pig's serum (1 :10) 1.0 c.c. 

Tube 3. 

Normal blood-serum 0.2 c.c. 

The organic extract (tested) 1.0 c.c. 

Guinea-pig's serum (1 : 10) 1.0 c.c. 

Tube 4. 

Normal blood-serum 0.2 c.c. 

Physiologic salt solution 1.0 c.c. 

Guinea-pig's serum (1 : 10) 1.0 c.c. 

The last three tubes serve merely for comparison to make 
sure that there are no accidental errors which render the test 
unreliable. The four tubes are shaken and placed for thirty 
minutes in the incubator at 99° F. To each then is added 1 
cubic centimeter of the 5 per cent, suspension of sheep's blood- 
cells and the reaction is then watched in the incubator. 

Usually in tubes 2 and 4 the contents become clear in from 
fifteen to thirty minutes. Hemolysis then appears in tube 3. 
When the blood-corpuscles in tube 1 dissolve almost simultane- 



IMMUNIZATION. 101 

ously with those in tube 3, the patient is free from syphilis. On 
the other hand, if the contents of tube 1 do not dissolve, the sus- Negative. 
pected patient has syphilis. The test is of no vakte unless the 
contents of tube 2 completely dissolve. If the contents of tube 1 Positive, 
dissolve imperfectly about half an hour or so after hemolysis in 
tubes 2 and 3, the existence of syphilis is possible, and therefore 
we must start the test again with tubes 1 and 2, but with smaller 
quantities of the patient's serum, e.g., 0.15 cubic centimeter. If 
this is not successful, we repeat the test with 0.1 cubic centimeter 
and again with 0.05 cubic centimeter of the patient's serum, 
endeavoring to find that combination which will allow the con- 
tents of tube 1 to remain intact while those of tube 2 to dissolve 
completely. If this is obtained the diagnosis of syphilis is still 
fairly certain. 

If the contents of tube 2 do not dissolve completely, we 
should add to tubes 1 and 2 from 0.1 to 0.2 cubic centimeter of 
human normal serum from fifteen to thirty minutes after (to 
make sure that the contents of tube 2 do not dissolve) the addi- 
tion of the 5 per cent, solution of the sheep's blood suspension. 
The idea is to find for tube 2 the amount of normal human serum 
that will exactly dissolve its contents, and then to use the same 
amount for tube 1. 

Judging by the conclusions arrived at by different clinicians, 
the serum reaction for syphilis is specific and found positive in 
from 90 to 95 per cent, of all cases with syphiHtic manifestations. 
It is invaluable, especially in the detection of latent forms of the 
disease. 

SERUM DIAGNOSIS OF TYPHOID. 
(Griiber-Widal.) 

. The blood of persons suffering from typhoid, when added to 
a broth culture of typhoid bacilli, arrests the characteristic move- 
ments of these germs and produces their agglutination and sedi- 
mentation. This phenomenon may be observed macroscopically 
in a suspension of bacteria in test tubes ; or, microscopically, when 
the bacteria are mixed with the blood and mounted in a hanging pog^j^Q 
drop preparation. The test is generally positive in typhoid AffJ^^ay 
patients after the fifth day of the disease and several weeks 
thereafter. 

The blood (or serum from a blister) is obtained from the 
skin covering the ear lobe. After cleaning this part, the lobe is 
pricked with a sterile needle, and two drops of blood are placed 



102 



PREVENTION AND CONTROL OF DISEASE. 



on a glass slide, one near either end and allowed to dry in the 
air. The examination can then be undertaken any time there- 
after by diluting one drop of the blood in ten or twenty parts 
of the typhoid culture. 




Fig. 27. — Stages in Widal Reaction. (After Robin.) 



IV. MATERIA MEDICA AND THERAPEUTICS. 

(Including Hydrotherapy, Electricity, Massage, Climato- 
therapy and Organotherapy.) 

No one method of treatment suits all cases. Some diseases 
subside spontaneously, if left alone ; others go from bad to 
worse if not treated promptly and energetically. Some affec- 
tions yield readily to biologic remedies, others to crude drugs 
or synthetic pharmaceutical preparations, and again others 
respond to change of climate, mode of living and eating, and 
to remedial measures other than pharmaceutical, such as 
hydrotherapy, massage, electricity and the like. 

Our duty being to alleviate suffering, we owe it to our patients 
to keep pace with the advances of the time and to employ every 
useful method of treatment regardless of its source or charac- 
ter. ''The period of exclusiveness is past." While a certain 
Conservatism degree of couscrvatism is always wise and safe, skepticism to 

versus *^ -^ ^ 

nihilism, well-tried remedies is worse than folly. 

HYDROTHERAPY. 

The virtue of water as a therapeutic agent varies with 
the idiosyncrasy of the patient, the temperature of the water 
employed, and the method of its application. 

Heat applied to the surface of the body produces a relaxation 



MATERIA MEDICA AND THERAPEUTICS. 



103 



of the vasomotor system. The cutaneous vessels dilate and 
become more active, diaphoresis ensues, and effete matter is 
eliminated. The volume of blood in the deeper structures is 
diminished ; hence, congestion relieved. The temperature of 
the body is first increased, but after free diaphoresis consider- 
ably lowered. 

Cold contracts the terminal blood-vessels and stimulates the 
internal circulation. It reduces the temperature of the body not 
only by conduction but also by inhibition of heat production. 
Soon after discontinuance of the cold a reaction takes place, 
respiration becomes deep and full, more carbon dioxid is excreted 
and the supply of oxygen is increased. The pulse, which is at 
first feeble, soon becomes full and strong ; the chilliness and rigor 
disappear, and a sensation of warmth pervades the body surface. 
The blood-current in the capillaries becomes gradually acceler- 
ated and the internal circulation relieved of its tension. 

The External Use of Water. — Neither extreme heat nor 
extreme cold should be employed in the treatment of diseases of 
children. Heat should be avoided on account ^ of the severe 
depression, and cold because of the shock it is apt to produce. 

Cold Sponging. — In the employment of cold water in the 
treatment of diseases of children, sponging advantageously sup- 
plants the cold bath. The temperature of the water should vary 
between 70° and 90° F. Three basins of water, one each of 70° 
F., 80° F. and 90° F., respectively, are placed at the bedside. The 
child is stripped and laid upon a blanket, and by means of cloths 
the surface of the body is sponged for from two to three 
minutes, in the following order of succession : face, neck, chest, 
back, abdomen, buttocks, upper and lower extremities. The 
warmest water (90° F.) is used first and the coldest (70° F.) 
last. Each part of the body should be thoroughly dried imme- 
diately after it has been sponged. The indications for the use of 
the sponge bath are hyperpyrexia and nervous irritability ; con- 
stitutional disorders, such as anemia chlorosis, scrofula, etc., 
and in cases in which a general tonic effect is desired. In the 
latter conditions sponging should be followed by active friction. 

Cold Wet Pack. — The child is stripped and blankets are placed 
over and under it. A small sheet is dipped in water at a tem- 
perature of 70° to 90° F., thoroughly wrung out and wrapped 
loosely around the patient. The child's body is then envel- 
oped in the blankets. To reduce high temperatures, for ex- 



Dilatation of 
cutaneous 
blood- 
vessels. 



Contraction 
of terminal 
blood- 
vessels. 



Antipyretic. 



104 PREVENTION AND CONTROL OF DISEASE. 

ample, in typhoid or pneumonia, ice may be rubbed over the 
chest. The next pack is applied after an interval of ten 
minutes and may be repeated from ten to twelve times in 
tv^enty-four hours. The feet should be kept v^arm by artificial 
heat. 

Vapor Pack. — If the cool wet pack is allowed to remain in 
position for from one to two hours and loss of body heat pre- 
vented by thoroughly covering the child with woolen blankets, 
the cold pack is converted into a warm pack which produces 
effects similar to those obtained from a vapor bath ; namely, free 
diaphoresis, lowered activity of the nervous system, calm and 
repose, and equalization of the internal circulation. The vapor 
In nephritis, pack is, therefore, invaluable in acute catarrhal conditions of 
the air passages, in nephritis, dropsical effusions, muscular 
rheumatism, eclampsia, hyperesthesias, etc. 

Wet Local Compresses (Priessnitz) — Cold Compresses. — 
These are applied in all forms of local inflammation, to relieve 
pain, swelling, heat and redness. In order to obtain good results, 
the temperature of the water should vary between 50° and 60° F., 
and the compress left in place and kept cold either by frequently 
In local sprinkling cold water over it or by the application of an ice-bag. 
tions. Indications : Meningitis, angina, acute pharyngitis and laryngitis, 
hemoptysis, appendicitis, intestinal hemorrhage, etc. 

Warm Compresses. — While cold compresses delay the flow of 
blood and cell-activity, warm compresses accelerate the blood- 
current and promote cell-activity. They are applied by means 
of cloths immersed in water at a temperature of about 100° F., 
thoroughly wrung out, and then covered with flannel and rubber 
tissue or oiled silk to prevent rapid evaporation and cooling. 
The compresses should be changed as soon as they become dry. 

Indications : Neuralgia of the head ; throat affections after 

subsidence of the acute inflammatory stage, to promote absorp- 

in local tion of diseased products; in exudative pleuritis; in bronchitis, 

^^spasm. to allay severe cough and to promote expectoration; in all 

spasmodic conditions of the intestines ; to hasten suppuration and 

relieve stasis. 

Baths. — Tepid Bath. — This is a very useful bath in children. 
The temperature of the tepid bath varies between 85° F. and 
92° F. It is employed in diseased conditions requiring sooth- 
^ ^^fevers^ ing, for example, in eruptive skin diseases and as an antipy- 
retic in infectious diseases. 



MATERIA MEDICA AND THERAPEUTICS. 105 

Warm Bath. — In a general sense, this is the most valuable 
bath in the treatment of diseases of children. It tranquilizes the 
nervous system, equalizes the circulation, produces diaphoresis 
and reduces temperature. 

Indications : All spasmodic conditions ; affections of the lungs 
and kidneys; exanthematous diseases, and nervous affections, sedative, 
such as hysteria, etc. The temperature of the bath should vary 
between 92° F. and 98° F. The patient should remain in the 
bath for from two to five minutes. The warm bath is sometimes 
employed as a pennanent hath, in extensive burns and wounds, 
and in skin diseases associated with intense itching. The patient 
is suspended in the bath on a sheet. The water is kept at an 
equal temperature by proper arrangement of inflow and outflow. 

Hot Bath. — The temperature of the hot bath may be carried 
as high as 108° F., and the patient should remain in the bath for 
from one to three minutes. It is very useful in collapse, con- 

... In collapse; 

vulsions and chronic rheumatic conditions. It is occasionally convulsions. 
administered to break up a "cold," and to produce rapid dia- 
phoresis. While in the bath the patient's head should be kept 
cool by an ice-bag. 

Shower Bath. — Cold shower baths are generally given for ^^^^^ 
their stimulating effect. Hence, they are of great value in stimulant. 
nervous affections, such as neurasthesia; in enuresis, and as a 
general tonic. For these purposes one shower (shock) at a time 
is sufficient. The shower bath should be followed by active 
friction. 

Aspersion Bath. — The value of cold water dashed suddenly 
over the frame or directed in a steady, broad stream upon some 
particular part, is very great. The cases in which such a mode 
of treatment is beneficial are numerous. The following are a 
few of the more important : Where the muscular power of a leg 
or arm is impaired from long inaction, as in cases of frac- stimulant, 
ture, dislocation, bandaging, sprains and partial paralysis. The 
patient sits in a bath-tub or on the floor and the operator, stand- 
ing on a table, directs the stream of cold water upon the affected 
part from a watering-can from which the sprinkler has been 
removed. This mode of treatment is rendered particularly 
serviceable if the circulation is quickly restored by vigorous dry 
friction for several minutes. It is also efficacious in systemic 
poisoning from drugs, suffocation from noxious gases, etc. 



106 PREVENTION AND CONTROL OF DISEASE. 

Medicated Baths. — Aside from the natural mineral baths 
obtained in the celebrated spas, which will be discussed later, a 
number of artificial baths are commonly used in the treatment 
of diseases of infancy and childhood. The efiicacy of these baths 
is, in the majority of instances, due probably to the effects of 
heat or cold and friction employed with the non-medicated bath. 

Aromatic Bath. — About six ounces each of chamomile flowers, 

calamus roots and peppermint leaves are tied up in a muslin bag 

stimulant, and thrown into a warm bath. Aromatic baths are recommended 

in marasmus, infantile spinal and other forms of paralysis, in 

sclerema, etc. 

Bran Bath. — Two or three pounds of wheat bran are boiled 
for about an hour in about three quarts of water. The decanted 

In skin ... ...... 

diseases, liquid IS added to the bath. It is useful m intertrigo, eczema, 
pemphigus, lichen, strophulus, etc. 

Malt Bath. — A few ounces of malt extract are added to the 
bath. Malt baths are recommended in rachitis, spasm of the 
glottis, and in general debility. 

Mercurial Bath. — This form of bath is employed as an adju- 
in syphilis, vant in the treatment of syphilis. It is usually prepared by the 
addition of 20 to 30 grains of calomel, or 0.5 to 1.0 gramme (gr. 
viiss to XV ) of bichlorid of mercury. 

Mustard Bath. — Two or three ounces of mustard are dis- 
solved in a few pints of tepid water and added to the bath. The 
temperature of the bath may vary between 100° F. to 106° F. 
It may be administered in the form of a sitz bath or full bath. 

To break •' . . 

up "cold." The patient should remain m the bath for from three to ten 
minutes. Mustard baths are indicated in collapse, shock or heart- 
failure from any cause, in sudden congestion of the lungs or 
brain, etc. 

Sea-salt Bath. — About two pounds of sea salt are dissolved 

stimulant, in the bath of four or five gallons of water. It is stimulating in 

its effects, and useful in rachitis, various forms of paralysis, etc. 

Soap Bath. — This form of bath is employed in the treatment 

dilea^s^S o^. pi"urigo, lichcn, strophulus, scabies, etc. It is prepared by 

the addition of from three to six ounces of soft green soap to 

five gallons of water. 

Sulphur Bath. — A half to one ounce of potassium sulphuret 
should be added to each bath. In some cases the addition of 
about three ounces of animal gelatin is of advantage. Sulphur 



MATERIA MEDICA AND THERAPEUTICS. 



10'; 



diseases. 



Diuretic. 



baths are deserving of recommendation in rheumatism, eczema, lYd^l^ 
prurigo, urticaria, lead poisoning, etc. 

The Internal Use of Water. — The benefits derived from the 
internal use of water are manifold, but unfortunately greatly 
underestimated. Water taken by the mouth in moderate quan- 
tities — large amounts weaken digestion — cleanses the alimentary 
canal, stimulates peristalsis and produces diuresis and diaphoresis. 
To a certain extent it acts also as a food. In acute diseases asso- 
ciated wath anorexia the free 
use of water will often sustain 
life for weeks. In febrile dis- 
eases water not only quenches 
thirst, but aids also in the re- 
duction of temperature. Water 
stimulates expectoration, and 
in the form of cracked ice 
checks vomiting. For the latter 
purpose small sips of hot w^ater 
are sometimes resorted to. 

Lavage. — Stomach washing 
in children is performed in the 
same manner as in adults. Its 
field of usefulness, how^ever, is 
much wider. It is invaluable 
in cases of acute simple and 
toxic gastritis, cholera infan- 
tum, chronic indigestion and 
difficult feeding. A funnel with 
a few feet of rubber tubing, 
to which a small soft-rubber 

catheter (No. 12 or 14) is joined by means of a glass cannula, 
is the best apparatus for stomach washing. About ten inches 
of the catheter should be passed beyond the lips. The 
temperature of the irrigating solution should be about 100° F., 
or higher, if special indications arise. The quantity of solution 
to be instilled varies with the capacity of the child's stomach. 
Generally, pure boiled water answers all medicinal purposes, 
except in poisoning, in which instance antidotes may be em- 
ployed. In hyperacidity of the stomach bicarbonate of soda or 
lime-water may be added. Lavasre is contraindicated in heart 




Fig-. 28. — Stomach Tube (ca- 
theter, rubber tube, glass con- 
nection, and funnel). 



Lavage. 



To cleanse 
stomach. 



Contra- 
indications. 



disease and hemorrhagic diathesis. 



108 PREVENTION AND CONTROL OF DISEASE. 

Irrigations. — The action of irrigations is chiefly mechanical. 
To cleanse They are indispensable in the treatment of divers affections of 
cavities, the lining membranes of internal cavities. In chronic cystitis, 
for example, washing of the bladder by means of sterile or medi- 
cated (boric acid, silver nitrate) water will often rapidly effect 
a cure. 

Irrigations of the vagina are frequently employed in vulvo- 
vaginitis. A slow current of water should be employed, per- 
mitting the fluid to return without injury to the adjacent parts. 
A fountain syringe with a small, sterile, soft-rubber catheter 
attached, generally suffices for ordinary purposes. The water- 
bag should be suspended about two feet above the child's body. 

Irrigations with warm, sterile water are very beneficial in ear 
affections, such as impacted cerumen, foreign bodies in the ex- 
ternal auditory meatus and external otitis. 

In febrile diseases, adenoids, chronic pharyngitis, etc., instilla- 
tions of weak salt water or ichthyol solutions prevent and cure 
affections of the nasopharynx and ear; it often also relieves 
reflex cough and embarrassed respiration. Instillation may be 
performed by means of a teaspoon or dropper, and should be 
repeated at least twice a day. 

Copious irrigations of the mouth with sterile or medicated 
(silver nitrate, hydrogen peroxid) water are invaluable in the 
treatment of grave forms of stomatitis. 

Enteroclysis. — The indications for low enemas are too well 
known to need further discussion. It may be mentioned, how- 
ever, that in habitual constipation only small quantities of water 
should be injected into the bowel. Large quantities are apt to 
produce atony of the colon by overdistention and thus aggravate 
the disease. 

High enemas are given by means of a flexible (colon) tube 
and a fountain syringe. High enemas not only remove effete 
material from the intestines, but by using water at a temperature 
Cleanser of 80° to 90° F. also rcducc temperature. Hence, they combine 
stimulant two therapeutic measures, which are of signal benefit in all 
gastrointestinal disorders, peritonitis, typhoid, etc. Soap-suds, 
turpentine, starch and salt, among other adjuvants, may be added 
according to indications. 

Saline injections stimulate the kidneys and promote elimina- 
tion of putrid material. They stimulate the circulation and supply 
the deficiency of body fluids in conditions associated with an 



MATERIA MEDICA AND THERAPEUTICS. 109 

excessive drain of fluids. Saline injections are, dierefore, a 

1 • • 1 • 1 r 1 r General 

sovereign remedy m uremia, typhoid fever, scarlet fever, small- stimulant. 
pox, measles, diphtheria, eclampsia, anemia, hemorrhages, and 
in shock after surgical operations, etc, 

A physiological (0.9 per cent.) salt-water solution at a tem- 
perature of from 100° to 110° F. is generally used. It should be 
injected slowly through a colon tube, and continued for from 
fifteen to twenty minutes. 

Saline injections are contraindicated in chronic kidney 
disease. 

Hypodermoclysis. — Subcutaneous injection of salt water 
(110° F.) is performed by means of an ordinary fountain syringe 
with an antitoxin syringe-needle attached. The needle and skin 
should be rendered aseptic. The injection should be made in 
places where there is an abundance of subcutaneous cellular 
tissue, for example, the anterior surface of the abdomen and 
thorax. The current should be very slow, and the quantity of 
the saline solution to be injected should vary between from two 
to six ounces, according to age and indications. Hypodermo- 

i . . . . . , , , . - ,, , . - In collapse, 

clysis IS of inestimable value in cases of collapse resulting from especially 

, , . . . . . , , from loss 

hemorrhage ; m pneumonia ; uremia ; acute gastroenteritis with of blood, 
great loss of body fluids ; and in leukemia. It should be pre- 
ferred to intravenous infusion, 

ELECTRICITY. 

Electricity as a remedial agent in the treatment of diseases of 
children is employed in the following forms, in the order in 
which they are named : Galvanic, Faradic and Static. 

The Galvanic Current. — The effect of the galvanic or direct 
current on the muscle is to produce contraction. The contraction 
takes place at the moment the current is closed or opened (make Nerve and 

. . ^ muscle 

or break). The galvanic current, if applied by means of two stimulant, 
electrodes along the course of a motor nerve, produces a uniform 
contraction of the entire muscle supplied by that nerve. The 
reaction produced by the constant current upon the sensory 
nerve varies according as the application is made with the positive 
or negative electrode, the anode being sedative in its effects, the 
cathode stimulating. A constant current of suitable strength — 
10 to 15 milHamperes— passed through living tissues causes, at 
the point of contact of the anode, an accumulation of oxygen, 
chlorin and acid ; coagulation and shrinking of the exposed 



Tonic and 
sedative. 



110 PREVENTION AND CONTROL OF DISEASE. 

tissue — positive electrolysis. On the other hand, if the cathode 
is brought in contact with Hving anmial tissue, hydrogen and the 
alkahes are set free, and Hquef action of the parts adjacent to 
the electrode takes place — negative electrolysis. 

The Faradic Current. — The faradic or induced current 

Nerve and causcs Contraction of muscles and nerves and is very effective in 

stimulant, producing muscular massage. It stimulates nerve action and 

nutrition, excites secretion, and arouses latent physiological 

function. 

The Static Current. — The static current produces vivid and 
persistent contraction of a large group of muscles with a mini- 
mum of pain. The second prominent characteristic of this cur- 
rent is its power of relieving pain. 

The following rules should be borne in mind : — 

1. Always administer the weakest possible current that will 
cause muscular contraction. 

2. Never employ electricity in the inflammatory stage of 
organic disease. 

3. In applying electricity to muscles always endeavor to 
separately reach the electromotor points. In deep-seated muscles 
the current should be applied along the course of the nerves 
supplying them. 

4. Each electric treatment should last no longer than twenty 
minutes, and no one muscle should be subjected to the currents 
for more than three minutes. 

The indications for electricity in the treatment of diseases of 
children are practically the same as in adults. The discussion 
of the subject will, therefore, be limited to diseases in which 
electricity is of undoubted value. 

Chronic Constipation. — The galvanic or faradic current may 
be used. One electrode is passed successively over different por- 
tions of the abdominal wall, and the other electrode is placed 
upon any other part of the body. The electric treatment should 
be continued for a long period. 

Diphtheritic Paralysis. — In this condition, faradization of the 
respiratory muscles, particularly the diaphragm, is of some 
service. It should be used in attacks of respiratory failure and 
continued while they last. 

Enuresis. — The broad anode is placed over the lumbar region 
of the spine and the small cathode over the region of the bladder 
or upon the perineum, allowing quite a strong galvanic current to 



MATERIA MEDICA AXD THERAPEUTICS. lU 

act for from two to four minutes. Sometimes faradization vaiue of 
proves effective. The wire end of a conducting cord, connected d^iSent^ ^" 
with the negative pole, should be introduced into the urethral '^^^^^^^^■ 
orifice for from one to two centimeters and quite a strong faradic 
current allowed to act for from one to two minutes. 

Facial Paralysis. — This form of paralysis is greatly benefited 
by a weak stabile galvanic current. It should be employed four 
to six times a week, for from two to three minutes at a time. 
The anode should be placed in the auricular fossa and the cathode 
upon the muscles of the aft'ected side ; or the anode may be 
placed behind the ear while the different nerve branches and the 
muscles are slowly stroked with the cathode. In later stages 
faradization also is of service. 

Hysteria. — The vague disconnected symptoms of hysteria call 
for general electric treatment, and no form of electricity so 
advantageously combines tonic and sedative effects as the static 
current. A mild current should be employed. Two or three 
treatments a week will generally suffice. Galvanism and fara- 
dism also are of service, especially in hysterical contractures. 

Multiple Neuritis. — The application of electricity to the 
affected muscles is important in order to maintain their nutri- 
tion. It should be begun after the acute stage has passed, that is, 
at the end of from three to four weeks. A moderate faradic 
current may be used if the muscles respond to it; otherwise a 
voltaic. The electricity should be applied daily by means of large 
electrodes, so that the current may reach as much muscular tissue 
as possible. The current should be strong enough to produce 
visible contraction of the muscles. 

Poliomyelitis. — The galvanic current gives the best results. 
It should not be employed earlier than the third or fourth week. 
A large, flat electrode, well moistened in salt water, is placed 
upon the spine over the affected region and the muscles repeat- 
edly stroked by means of a small electrode. The current should 
be of such strength as will produce visible contraction of the 
muscles, without, however, causing severe pain to distress the 
child. 

Rheumatism. — The sequelae of rheumatism, atrophy and con- 
tractures, often call for electric treatment. The galvanic, faradic 
or static current may be employed. It is sometimes advantageous 
to use the galvanic and faradic currents at one sitting. The 
treatment should be repeated at least every alternate day and 



112 PREVENTION AND CONTROL OF DISEASE. 

continued for several months. In muscular contracture the anode 
should be placed over the portion of the spine governing the 
contracted muscles and the cathode over the muscles themselves. 
For the relief of pain the positive pole should be applied to the 
most painful spot. 

Tetany. — Electric treatment has been followed by improve- 
ment in a number of cases. The stabile galvanic current should 
be employed; the negative pole to the spine and the positive to 
the irritable nerve trunks. 

Torticollis. — A weak galvanic current is frequently very 
serviceable. The positive pole should be placed just below the 
occiput and the negative pole allowed to act upon the contracted 
muscles for from five to ten minutes. 

The indications for electrolysis are identical with those in 
adults. 

MASSAGE. 

Massage is a mechanical form of treatment consisting of 
intelligent manipulations of the superficial parts of the body. It 
is intended to produce changes in the local and general nutrition, 
action and other functions of the body. 

Indications. — Massage is indicated in hysterical, paralytic, 
stimulant, rlieumatic and traumatic contractures of joints; in fractures, to 
hasten absorption of callous masses ; in chronic glandular enlarge- 
ments; in swelHngs associated with rheumatism, sprains, con- 
tusion, etc. ; in torticollis, to relax muscular contraction ; in con- 
stipation, atonic dyspepsia and gastric dilatation ; in all forms of 
To remove muscular atrophy or dystrophy ; as a general stimulant in cases 
factions" of prolonged muscular inactivity, whether from indolence, dis- 
ease, feebleness (rachitis), or prolonged use of splints or braces, 
or other cause ; in various forms of paralysis, to improve the 
nutrition and function of the affected muscles. 

Contraindications. — Massage is contraindicated in children 
suffering from gonorrheal rheumatism or peliosis rheumatica; in 
tuberculous, t3^phoid or syphilitic ulcerations of the intestines; 
in acute peritonitis, appendicitis, gastroenteritis, gastric ulcer ; in 
tubercular glandular enlargements. 

Massage is generally divided into the following principal 
manipulations : — 

Effleurage or Stroking. — In making the strokes both hands are 
employed. The limb is grasped with one hand just above the 
other, in such a manner that pressure is exerted to some extent 



MATERIA MEDICA AND THERAPEUTICS. 113 

by the whole palm, but especially the ball of the thumb and the 
inner surface of the last two phalang^es of the fino^ers. The 

11- i-ir r 1- -11 Methods of 

strokes are delivered m the form of an ascendmg spiral, the two application, 
hands being moved simultaneously in opposite directions, the 
lower following closely upon the upper. The strokes must be 
made with great regularity. Light stroking has a soothing 
influence; heavy stroking stimulates the superficial structures 
increasing the arterial, venous and lymphatic circulation. 

Friction. — This manipulation is performed with the finger- 
tips and consists of firm circular, semicircular, or to and fro 
movements. It is usually combined with effleurage and is intended 
to promote absorption by the veins and lymphatics. 

Petrissage or Kneading and Pinching. — In kneading the en- 
deavor of the operator is to pick up the individual mwscle or 
muscle-groups between the fingers of the two hands, or in some 
cases between the thumb and finger of one hand, and then to roll 
and squeeze the muscle with a double movement. These ma- 
nipulations cause circulatory, nutritive and alterative changes in 
the muscles, tendons and organs within reach. 

Tapotement, Percussion or Tapping. — Percussion is made 
either with the points of the fingers brought into a line with one 
another or with the side of the hand and fingers. The movement 
should be very rapid and elastic. These manipulations are usually 
employed on muscular parts, such as the back of legs and gluteal 
regions. The efi^ect of tapotement is similar to that obtained by 
petrissage. This manipulation may be enforced also by vibra- 
tions, that is, by rhythmic, tremulous movements under pressure. 

Generally, all the movements are practised at one sitting, thus, 
efileurage, friction, petrissage, tapotement and vibration. The 
treatment is concluded by efileurage. While in local afiiections 
local massage is generally sufficient to efifect the desired results, 
it is always advantageous to supplement the local treatment by 
general massage. The duration of each seance varies from a 
few minutes to a quarter of an hour. At first the treatment 

^ Gentle 

should not last more than five minutes. No force should be manipulation, 
used, and the delicate skin of the child should be spared unneces- 
sary injury. It is, therefore, advisable to anoint the skin wnth 
boric acid vaselin, cocoanut oil or any other emollient. In young 
infants massage should be limited to general friction of the body. 
In cases of malnutrition it is a good rule to give a fat-inunction 
daily after the morning bath. 



114 



PREVENTION AND CONTROL OF DISEASE. 



Mountains. 



CLIMATOTHERAPY. 

Change of climate has from time immemorial been recognized 
as a therapeutic measure par excellence, and, fortunately, our 
great country abounds with vast mountain, seashore and inland 
resorts, which rival, if not surpass, the most celebrated spas of 
Europe. 

In selecting a suitable health resort, we should bear in mind 
Importance not Only the State of health and the peculiarities of the individual 

of Individ- . "^ ^ . 

uaiization. patient, but also the local conditions of the particular resort, such 
as the drainage, water supply, prevalence of epidemic or endemic 
diseases, etc. 

The air of mountainous regions is rarefied, dry, cool, bracing 
and free from organic and inorganic impurities. It improves the 
action of the skin; favors deeper expansion of the lungs, and 
correspondingly accelerates the heart's action, improves sleep and 
stimulates the appetite and the powers of assimilation. Moun- 
tain air, therefore, is particularly beneficial in chronic disorders 
of the alimentary tract and liver ; in anemia ; in divers respiratory 
affections ; in malaria ; in rheumatism, and compensating heart 
disease. 

The climate of the seashore is pure and very strong. The air 
is loaded with moisture, and comparatively free from dust par- 
ticles, hence very beneficial to convalescents from pneumonia, 
pleurisy and empyema; also typhoid and surgical operations. It 
often acts almost specifically in acute gastroenteritis. 

The surf-baths are invaluable in cases of nervousness, rachitis 
and local tuberculosis. 

Dry, sheltered inland resorts are to be preferred for patients 
suffering from non-compensating heart disease; severe bron- 
chitis ; chronic kidney disease, and all such affections as are apt 
to be badly influenced by sudden variations of temperature. 

It is often of advantage to spend part of the summer months 
at the seashore and part time in the mountains or inland resorts. 
Young children suffering from tuberculosis will, during the winter 
months, derive the greatest benefit from a sojourn in New Mexico 
and Arizona. Children over ten years old often do well in colder 
climates, such as the Adirondacks. 



Seashore. 



Inland 
resorts. 



MATERIA MEDICA. 

As already suggested, quite frequently we have to resort to 
drugs for the relief and cure of the patient. It is very unfor- 



MATERIA MEDICA AND THERAPEUTICS. 115 

tunate that medical students are nowadays given so little oppor- 
tunity to familiarize themselves with the intrinsic value of a great 
number of old and new pharmaceutical products. I am firmly knowledge 

rGsoousiblG 

convinced that so-called "Medicinal Nihilism/' to a great extent, for 
is due to lack of knowledge of the physiologic action of the skepticism, 
numerous standard drugs and inexperience as to their indications 
and mode of administration. 



Palatable Medication. 

Palatable medication is, to say the least, highly appreciated 
by sick adults, and practically indispensable in the management 
of sick children. The physician who believes in the usefulness 
of the medicines he prescribes owes it to his patients that they 
are able to swallow and retain them. As a rule, adults manage, 
by means of condiments and pleasant beverages, to render drugs 
disgusting in taste at least acceptable. On the other hand, chil- 
dren are compelled to take the medicine as given to them, and 
what is still worse, the more they resist the more they are sub- 
jected to anguish and distress, nay, even to corporal punishment Forced 
which not infrequently borders on actual injury. Indeed, it is danffrSus. 
not at all rare to find children suffering from acute pneumonia in 
a state nigh to suffocation from the effects of prolonged and firm 
compression of the nostrils ; and many a child bleeds from gums 
and lips, and loses a tooth or two through the attempts of the 
overzealous mother to force down into the unfortunate's throat 
a teaspoonful of a miserable mixture — which was, perhaps, in- 
tended only as a placebo. 

As most drugs are now obtainable as solid or powdered 
extracts, whenever possible, older children should receive their 
medication in the form of freshly prepared pills or capsules, capsules 
Whenever the necessity arises to administer offensive fluid ex- cMidreiT. 
tracts or tinctures, essential oils and the like, it is best to order 
them in what I may venture to call ''home-made liquid capsules." 
The liquid medicine and the empty gelatin capsules are prescribed 
separately, and the patient is directed by means of a dropper to 
prepare each dose of medicine just before taking it. These 
''home-made liquid capsules" are quite a boon to patients who 
are averse to taking nauseous mixtures. By means of these 
capsules you can readily administer also the tincture of iron ftfJteeth. 
chloride, which in solution exerts a very destructive effect upon 



116 PREVENTION AND CONTROL OF DISEASE. 

the teeth ; or the different hygroscopic medicinal agents, such as 
the iodides, bromides, chloral, etc. 

Unfortunately this convenient way of dispensing non-palat- 
able drugs to older children cannot be taken advantage of in 
Selection prescribing for small children. Hence, an attempt will here be 
paiaSbie made to devise other means, based chiefly upon the selection of 
prepara ions. ^-^^ fittest and most uscful preparations, which will enable the 
physician to render the giving and taking of medicine an act of 
benevolence rather than an act of cruelty. 

For the sake of convenience and in order to avoid repetition 
the usual classification of drugs in accordance with their thera- 
peutic effects will here be followed. 

Digestants. — Most of the so-called appetizers and digest- 
ants, such as the pepsin and pancreatin preparations, can be made 
pleasant in taste by the addition of sugar or in solution with 
sweet wine or simple elixir. 

Bitter Tonics. — The simple bitters fully deserve their cog- 
nomen, since they are certainly very bitter, and simple, insignifi- 
Of little cant, in their therapeutical effect. The tinctures of gentian, 
value, quassia, and calumba owe their medicinal value chiefly to the 
alcohol they contain. Their use should, therefore, be discouraged, 
and, if alcohol be indicated, pleasant wines preferred. Of the so- 
called peculiar bitters, the cinchona preparations are the chief 
representatives. As their disgusting taste can almost never be 
disguised, they should never be prescribed for small children, 
unless intended as an antimalarial. In malarial conditions qui- 
nine can best be given by rectum in the manner suggested by me 
about nine years ago. A half to one dram of quinine sulphate 
or bisulphate and a few grains of salt are mixed with the white 
of an egg, and by means of a large glass syringe and wide but 
short rectal tube injected into the bowels. The white of egg 
prevents irritation of the intestine, and together with the salt 
aids in the absorption of the quinine. Older children should be 
coaxed to take quinine in freshly prepared capsules. The newer 
''tasteless" quinine preparations are also deserving of trial, and 
children not averse to bitter medicines can frequently be induced 
to take quinine in solution with the syrup of yerba santa, or 
licorice, or in powder form in sweetened chocolate. 

The different liquid iron preparations, such as the of^cial 
wine and the tincture of the chloride, may be rendered palatable 



MATERIA MEDICA AND THERAPEUTICS. 117 

by the addition of glycerin, syrup of orange, and water. Pow- 
dered iron goes well with sugar and chocolate. 

Mineral Acids. — Insufficient attention is being paid to the 
medicinal properties of mineral acids in the treatment of diseases 
of infancy and childhood. These acids advantageously replace instead 
bitter tonics and act specifically upon the alimentary canal and tonics, 
osseous system. Children like the taste of most of them if well 
diluted in sweetened water or in combination with raspberry or 
orange syrup and water. 

Alteratives. — Arsenic, iodine, and mercury are the leading- 
remedies of this group. Arsenic is best exhibited as Fowler's 
solution in plain water. Syrup of iron iodide with simple syrup 
forms a palatable and very useful hematinic and alterative for 
children. Sodium and potassium iodide may be prescribed in 
peppermint or orange-flower water with a little simple syrup, or 
in compound syrup of sarsaparilla, or elixir of taraxacum. The 
same holds good for corrosiA^e sublimate. Calomel, the prac- 
titioner's panacea, is readily taken by children in powder form 
with a pinch of sugar. 

Cod-liver oil, the almost indispensable tissue builder in all 
wasting diseases of children, is the stumbling block of the phar- 
maceutical reformer. Do what you please, cod-liver oil always 
tastes like cod-liver oil as long as there is any in the mixture. In 
infants cod-liver oil may be tried by inunction. The majority 
of children can be "bought" to like the following emulsion : — 

I^ Cod-liver oil 4 ounces | 120. 

Extract of malt, j 

S3'rup of calcium hypophosphite aa 1 ounce i 30. 

Glycerin, j 

Powdered acacia aa Y^ ounce | 15. 

Cinnamon water q. s. ad 8 ounces | 240. 

Antipyretics and Antirheumatics. — The best antipyretic for 
children is water, externally and internally. If coal-tar products J^e^^est 
and the salicylates are indicated they may be administered in 
powder form triturated with a little sugar to which a minute 
quantity of essence of peppermint may be added to impart its 
taste. In prescribing sodium salicylate in solution its nauseating 
sweet taste may be disguised by a drop or two of the tincture of 
nux vomica. 

Hypnotics and Anodynes. — The selection of pleasant hyp- 
notics and anodynes is rather difficult, and perhaps fortunately 
so, in view of the very deleterious effect they exert upon the 



antipyretic. 



118 PREVENTION AND CONTROL OF DISEASE. 

delicate infantile organism. However, sometimes they are inclis- 
doses^ pensable, and in minute doses can readily be made palatable. 
This is particularly the case with the deodorated tincture and the 
wine of opium, which can be rendered more or less pleasant in 
taste in a mixture of glycerin and orange-water. The camphor- 
ated tincture of opium is a safer preparation for infants and may 
be prescribed in althea syrup and water. In dispensing the dif- 
ferent morphine derivatives, it is advantageous to add a little 
syrup or powder of acacia to the mixture in order to avoid the 
formation of a sediment. In excessive irritability of the stomach, 
the opiates, the bromides, chloral and the newer hypnotics should 
^and if^^o^ be administered by rectum, and on rare occasions morphine may 
dermaticaiiy. ^Iso be givcu hypodcrmatically. 

Antispasmodics. — Belladonna is the principal drug of this 
group ordinarily employed in diseases of children. The fluid 
extract tastes fairly well in combination with licorice and water. 
Spirit of camphor can be made quite palatable in syrup of wild 
cherry or simple elixir, and the powdered camphor loses part of 
its miserable taste in chocolate. The emulsion of chloroform 
and the compound spirit of ether are useful antispasmodics, and 
fairly palatable in syrup of orange, or almond, and water. 

Stimulants. — Nux vomica, strychnine, ammonia, alcohol, 
strophanthus, caflfeine, digitalis, and sparteine, all call for skill- 
^^^^an^d ^^^ compounding to make them at least acceptable. The extracts 
and alkaloids should at all times be preferred to tinctures, infu- 
sions, or decoctions. Thank heaven ! the times have passed when 
the greatness of the physician stood in direct ratio to the great 
quantity of medicine he prescribed ! As quick circulatory and 
respiratory stimulants the ammonia preparations, such as aro- 
matic spirit and the anisated solution, are very agreeable and effi- 
cient. It is truly sinful to prescribe ammonium chloride instead. 

Heart Sedatives. — There are but few occasions when these 
drugs are of actual benefit to children. Aconite, the standby of 
the homeopath, may be given in homeopathic doses well diluted 
in sweetened water. Aconite, like digitalis, is a dangerous drug 
remedies, jj^ ^]^g hands of the ignorant. The indication for aconite is sthenic 
fever, and there are not many children too vigorous while sick. 
Bitter-almond water in small quantities and well diluted is a use- 
ful addition to a palatable cough mixture. The same may be 
said of compound syrup of squill. 



alkaloids. 



Dangerous 



MATERIA MEDICA AND THERAPEUTICS. 119 

Emetics. — Although intended to disgust the patient, most 
emetics are not disgusting in taste. The wine of ipecac, requiring 
but small doses to produce the desired results, should be pre- 
ferred to the syrup or infusion. Whenever a quick emetic is 
indicated, apomorphine may be used hypodermatically, but very 
cautiously. No special effort need be made to make emetics for emesis. 
palatable. It is to be regretted that emetics are dropping into 
disuse, since many cases of acute gastritis can be arrested in 
their incipiency by the timely administration of an emetic. 

Laxatives, Cathartics, and Purgatives. — Very fev^ of the 
many members of these groups are being employed in the chil- 
dren's practice. Calomel and aromatic syrup or tincture of 
rhubarb answer the purpose in most cases. If castor oil is par- 
ticularly wanted, an emulsion may be made of the following 
ingredients : — 

B Castor oil 1 ounce I 30. 

Oil of peppermint 5 drops | 

Sugar 1 dram | 4. 

Mucilage of acacia and water q. s. ad 2 ounces [ 60. 

Rochelle salts with a little aromatic spirit of ammonia, glyc- 
erin, and water form a pleasant mixture. Podophyllin and 
aloin are best prescribed in suppositories of cacao butter. Finally, eSema! 
it is wxU worth remembering that an enema of soapsuds often 
dispenses with drugging. 

Anthelmintics. — Santonine and calomel, the most efficient 
vermifuges, are readily taken by children either pure or with a 
little sugar or chocolate. Their effect is greatly enhanced by 
enemas of soapsuds and turpentine, or a decoction of quassia 
wood. All teniafuges are very disagreeable in taste and irritating 
to the stomach. Male fern, the most active teniafuge, may be 
exhibited as follows : — 

I^ Ethereal extract of male fern 3 drams ] 12. 

Emulsion of chloroform 4 drams | 15. 

Emulsion of almond ... q. s. ad 2 ounces | 60. 

Failure to expel the worm is often due tO! the fact that an p^esh 
oleoresin is used which is prepared from old male fern. '^^^^• 

Diuretics and Diaphoretics. — Water is the most palatable 
and, in many diseased conditions, perhaps, most useful diuretic. 
It should always be thought of before resorting to offensive ^^^hiretic 
medicinal combinations. The alkaline diuretics, such as ammo- 
nium, potassium, and sodium acetate, as well as potassium 



120 PREVENTION AND CONTROL OF DISEASE. 

citrate, the lithium preparations and sodium benzoate, may be 
rendered palatable in any medicated water with a little syrup. I 
believe that sodium benzoate is not receiving due recognition as 
benzoate. a therapeutic agent. Being an active diuretic, diaphoretic, expec- 
torant, and antirheumatic, it forms, as fully demonstrated by me 
ten years ago, an ideal remedy for the grip and similar acute 
affections. The mode of rendering the "hydragogue" diuretics 
and "special" diaphoretics more or less pleasant in taste has 
been suggested when speaking of the "heart stimulants and 
sedatives." I may also add that high intestinal irrigation often 
advantageously supplants the internal administration of drugs. 

Expectorants. — Anisated solution of ammonia, compound 
syrup of squill, and wine of ipecac, which have already been 
referred to, are quite palatable and efficient expectorants. To 
these may be added syrup of senega, tincture of cubeb, com- 
pound mixture of glycyrrhiza, syrup of wild cherry, syrup of 
Tolu, and syrup of althea ; the last-named syrups serve also as 
Creosote excellent adjuvants. Creosote, the most valuable remedy in pro- 
remedy, tracted coughs due to pharyngeal, laryngeal, and bronchial 
catarrh, is fairly palatable in a mixture of glycerin and sherry 
wine or elixir aurantii. 

Astringents. — It will usually be found that bismuth and 
chalk mixture will do well in most cases where astringents are 
indicated. The following is a pleasant combination : — 

I^ Bismuth subnitrate or subcarbonate 4 drams | 15. 

Chalk mixture 4 drams | 15. 

Glycerin 3 drams | 12. 

Syrup of acacia 2 drams | 8. 

Peppermint water q. s. ad 2 ounces | 60. 

Krameria and tannic acid are best administered in enemas of 
starch and water. The different newer tannin preparations may 
be given by mouth with aromatic powder or peppermint sugar. 

Gastric Sedatives. — Last in line but primary in importance 
are the gastric sedatives, since a highly irritated stomach will 
often reject even the most palatable medicine. Cracked ice, cold 
or hot water, calomel and sodium bicarbonate, lime, peppermints 
or bitter-almond water, small doses of bismuth and cerium 
oxalate, minute quantities of tincture of iodine well diluted in 
plain or medicated water — are all useful and more or less pleas- 
Lavage ^'^^ gastric scdativcs. In continued vomiting of infants lavage 
advantageously supplants drugging. 



MATERIA MEDICA AND THERAPEUTICS. 



121 



In administering medicines to infants it is often very helpful 
to divide the regular dose into several smaller doses, giving it, 
if need be, drop by drop until the whole dose is consumed. In 
this manner the most irritable stomach will frequently retain the 
medication where it would otherwise reject it. Before prescrib- 
ing any nauseous medicine the physician should always bear in 
mind the grand dictum of Hillel, 

"What is hateful to thee, do not unto thy fellow-man." 
F'inally, let us remember that a great many drugs can now- 
adays be administered hypodermatically, a method of medication 
which is especially advantageous in the treatment of very sick 
children. 

ORGANOTHERAPY. 

Organotherapeutics, though still in the experimental stage, is 
rapidly assuming an enviable position in the field of specific 
medication. This is true especially of the thyroids, and less so of 
the suprarenals, pituitary and thymus glands. 

Their modus operandi upon the human economy — whether by 
regulation of metabolism, or neutralization of specific poisons — is 
still shrouded in mystery. It is definitely established, however, 
that they are all of fundamental importance to the health and 
growth of the human organism. Furthermore, evidence is grad- 
ually accumulating which goes to prove that : — 

1. Absence, atrophy or degeneration of the thyroid gland is 
followed by cretinism and infantilism; 

2. Absence or disease of the parathyroids gives rise to a state 
of tetany and disturbance of calcium metabolism^ ; 

3. The suprarenals exert a powerful influence over the dorso- 
lumbar sympathetic nerve system and upon the circulation 
(Addison's disease is generally associated with involvement of the 
suprarenals) ; 

4. Hypertrophy, and particularly tumors of the hypophysis 
are productive of gigantism or acromegaly, and, finally, 

5. Hypertrophy of the thymus gland is usually associated with 
"'status lymphaticus." 

From a therapeutic point of view the thyroid gland only has 
thus far met all expectations. It acts specifically in cretinism and 
myxedema, and is very serviceable also in obesity and pachyderma- 



Drop by 

drop 

doses. 



Regulates 

metabolism 

and 

neutralizes 

poisons. 



Cretinism. 



Tetany. 



Gigantism. 



Status 
lymphaticus 



Myxedema. 



1 Tetany and calcium deficiency forming conspicuous phenomena also 
of rickets, there is probably an etiologic relation between this disease and 
the functional incapacity of the parathyroids. 



122 PREVENTION AND CONTROL OF DISEASE. 

toses. The gland may be administered fresh (in soup) or dry. 
The dry preparations are usually given in from ^- to 3-grain 
doses twice daily, until the desired results have been obtained 
and in smaller quantities thereafter. Engrafting of the sheep's 
thyroid in the human body has met with some success. The para- 
thyroids are generally employed (gr. %o to ^) as adjuvant or 
substitute of the thyroid. 

The suprarenal solutions are used principally locally as hemo- 
Hemorrhages. static and astringent, e.g., epistaxis, rhinorrhea of divers origin. 
Internally, usually hypodermatically (5 min. of a 1:1000 solu- 
tion) ; its action resembles that of digitalis. 

The pituitary gland is highly recommended (gr. y^) m infan- 
tihsm, in hay-fever and asthma (topically as well is internally). 

The therapeutic application for the thymus gland is thus far 
limited to pronounced anemias and marasmus. The results are 
encouraging. 



Infantilism. 



CHAPTER III. 
Congenital Malformations. 



Congenital malformations depend upon the following causal 
factors : — 

1. Hereditary disposition {e.g., supernumerary fingers and 
toes). 

2. Antenatal constitutional diseases, especially syphilis and 
tuberculosis {e.g., hydrocephalus and spina bifida). 

3. Traumatism during pregnancy {e.g., multiple fractures 
and dislocations). 

4. Extra- or intra-abdominal pressure through pelvic 
deformities, tumors, etc. {e.g., talipes). 

5. Constriction by amniotic bands {e.g., amputations). 

CONGENITAL MALFORMATIONS OF THE HEAD. 
MICROCEPHALUS. 

We distinguish two varieties 
of microcephalus : One, which 
appears as a genuine hrain dis- 
ease and is the result of antenatal 
structural disease of the brain 
(inflammation, sclerosis, cystic 
degeneration) ; the other, which 
presents itself in the form of 
a miniature brain (abnormally 
small, but not necessarily dis- 
eased), is due to congenital 
arrest of development and leads 
to premature synostosis of the 
bone sutures of the skull. 

Microcephalus as a brain dis- 
ease presents typical symptoms 
of "cerebral paralysis" at birth 
or soon after. The child suffers 
from convulsions, rigidity of the 
entire body, anomalies of sensi- 
bility, involvement of the cranial ^r- on tit- , , , . 

. . 1 . ., r ^^S- 29.— Microcephalus— bram 

nerves and later disturbances of disease. (Sheffield.) 

(123) 




Brain 
disease. 



Miniature 
brain. 



Symptoms 
of cerebral 
paralysis. 



124 CONGENITAL MALFORMATIONS. 

locomotion and signs of mental degeneracy, the latter symp- 
Mentai toms gradually getting worse. The head is small compared with 
ness. that of a normal child, but not exceptionally so. On the other 
hand, in miniature brain, the mental deficiency predominates 
while the physical signs are comparatively slight and are apt to 
improve as the child grows older (see page 570). Treatment 
by means of massage, electricity and baths may improve the 
paralytic symptoms. 




Fig. 30. — Microcephalus — miniature brain. (Sheffield.) 

CONGENITAL HYDROCEPHALUS.! 

Hydrocephalus is recognized chiefly by the increased size of 
the head. The enlargement is not always symmetrical on the 
head, two sides. All are more or less plagiocephalic, but some are 
rounded and brachycephalic and others dolichocephalic or 
scaphocephalic. Hence, the measurements of the head must 
embrace not only the transverse diameter from one mastoid 
process across the vertex to the other, and the longitudinal 



1 See "Acquired Hydrocephalus," page 516. 



CONGENITAL MALFORMATIONS OF HEAD. 



125 



diameter from the glabellum across the vertex to the occipital 
tuberosity, but particularly the circumference — with the 
glabellum and occipital tuberosity as centers — the measure- 
ment of which greatly exceeds that of the normal child (see 
page 4). Due allowance, however, should be made for the 
increased measurement observed in rickety projection of the 




Fig. 31. — Congenital Hydrocephalus. (Sheffield.) 



parietal bones. In the typical hydrocephalic the fontanelles 

are widelv open, the sutures separated and the bones vield to ^p^^ ^o^^^^^- 

. , -^ nelles and 

pressure with the nns^er, usuallv to a much PTcater extent sutures. 

1 . . . . ™, , , ' . ^ Parchment- 

tnan m rachitis. ihe head sometimes attains an enormous ^^^^ 

consistence 

Size, so that the child is often unable to hold it up — it shakes ?^ cranial 
to and fro and from side to side- 



the delicate, emaciated face. 



-and contrasts strangely with 
The skin of the head is verv thin 



bones. 



126 CONGENITAL MALFORMATIONS. 

and tense and traversed by dilated veins. The orbital plates 
are pushed downward and the eyeballs forward, so that the 
lids remain partially retracted, leaving a ring of the sclerotic 
exposed. Hence the peculiarly staring expression, which is 
greatly exaggerated by the not infrequent accompaniment of 
strabismus, nystagmus, and optic atrophy — the result of 
pressure. 

The brain symptoms of true hydrocephalus depend upon the 
amount of cerebrospinal fluid and relative size of the skull cavity 
and the resultant pressure atrophy of the brain. Where the 
brain remains unimpaired, the child may grow up apparently 
healthy in mind and body. This may occur, though less fre- 
quently, also with cases in which the disease comes to a standstill. 
In the majority of instances, however, the symptomatology of 
hydrocephalus is very definite and progressive in character. 
Defective Visiou and hearing are frequently defective ; intelligence is 
hearing and impaired and ranges between simple dullness up to total idiocy. 
Not rarely hydrocephalus is associated with paraplegia, epilepti- 
form attacks, disturbance of the motor functions and spastic 

symptonis'. Contractures of the upper extremities, spasmus glottidis, and 
similar spasmodic manifestations. In congenital cases the course 
of the disease is rapid and death usually occurs in the first few 

Marasmus, months of life in consequence of marasmus (notwithstanding 
good appetite and perfect digestion), intercurrent diseases, 
convulsions and coma. The prognosis is most favorable in 
syphilitic hydrocephalus, especially if specific treatment is begun 
early. Antisyphilitic medication should be tried in all cases 

Spinal and irrespective of cause, and where the exudation is marked this 

puncture, should be Supplemented by lumbar puncture (once a week), or 

possibly puncture of the lateral ventricles followed by firm but 

strapping, evcu Strapping of the skull. Cases of hydrocephalus with idiocy, 
spina bifida, etc., are best left alone. 



CEPHALOCELE (HERNIA OF THE BRAIN). 

Meningocele, Encephalocele, Encephalocystocele or Hy- 
drencephalocele. — Congenital defects in the cranial bones 
permit the protrusion of a portion of the contents of the skull. 
The hernia may consist of : — 



CONGENITAL MALFORMATIONS OF HEAD. 127 

(a) Meninges (which form the hernial sack) with or with- JJo^^jf^j^'^' 
out cerebral fluid — Meninc/oceleA ^^^^^ 

. ^ meningocele. 

(b) Meninges and brain substance — encepJialocele. 

(c) Meninges and brain substance, which enclose a cavity 
which is filled with fluid and communicates with a cerebral ven- 
tricle — hydrenccphalocele or cncephalocystocele. 

In accordance with their location we distinguish the following 
forms of cephalocele : — 

{a) Cephalocele occipitalis superior — situated above the ex- 
ternal occipital protuberance. 

{h) Cephalocele occipitalis inferior — situated below the pro- 
tuberance. 

(c) Cephalocele nasofrontalis — emerges from above the nasal 
bones.. 

{d) Cephalocele nasoethmoidalis — situated below one of the 
nasal bones. 

(<?) Cephalocele naso-orbitalis — appears at the inner angle of 
the eye. 

The presenting tumor varies in size from a small nut to a 
fetal head. It may be flat, sessile, hemispherical, pear-shaped or 
pedunculated. Small tumors are soft and elastic, larger ones 
pulsate and are often translucent. They enlarge during crying, 
and may be reduced in size by compression, — a procedure which 
is usually attended by meningeal disturbances. By bearing in 
mind the characteristic signs, there ought to be no difficulty in 
difrerentiating cephaloceles from extracranial cysts, hematomas, 
abscesses, etc. The diagnosis may be facilitated by an X-ray 
examination, showing the edges of the opening in the bone. 
Cephaloceles may remain small and give rise to but very little 
disturbance. As a rule, however, they grow rapidly and produce 
death from meningitis, convulsions, or rupture, or proceed a 
slower course manifested by more or less pronounced backward- 
ness in physical and mental development and other evidences of 
organic brain disease. 

Small cephaloceles require no surgical interference, but 
merely protection against external injuries by suitable caps, etc., 



Reducible 
on pressure. 



Protection. 



1 Congenital meningocele is not to be confounded with acquired 
so-called pseudomeningocele or meningocele spuria s. traumatica, 
which is either a result of trauma during delivery or a carious process, 
especially syphilis. Here the tumor is usually situated at one of the parietal 
bones, increases in size with the development of the brain or enlarge- 
ment of the cleft in the bone. 



128 CONGENITAL MALFORMATIONS. 

^^^°^'and ^^' gentle compression after reposition of the protrusion. Inoper- 
compression. ^-^i^ cases are those compHcated by pronounced flattening or 
diminution in size of the skull, by hydrocephalus or other serious 
malformations, or where the cleft in the skull reaches down to 
the foramen magnum. In all other cases removal of the growth 
is the only proper treatment, followed, if necessary, by osteoplas- 
tic closure of the defect in the skull. 

The operation is not rarely successful, if performed by a 
skillful surgeon, and, in view of the extremely grave prognosis 
^ in large tumors if left alone, there is sufficient justification for 
operation, early ( !) surgical interference. 

CONGENITAL MALFORMATIONS OF THE FACE. 

Including those of the Palate, Mouth, Eyes, Nose, and Ears. 

CLEFTS OF THE FACE AND LIPS. 

1. Median, the result of non-union of both globular processes 

of the central nasal process. This cleft is rarely extensive. 

2. Lateral (Labium Leporinum, Harelip, Cheiloschisis), pro- 

duced by failure of union of one or both globular processes 
with the superior maxillary processes. Clefts of the upper 
lip may accordingly be unilateral or bilateral, may exist as a 
mere notch into the skin margin of the lip, or more fre- 
quently extend for some distance upward, involving the 
whole lip, nostril and upper jaw. It is occasionally asso- 
ciated with cleft palate. 

3. Oblique (Meloschisis), arises from defective closure of the 

groove between the lateral nasal process and the superior 
maxillary process. The cleft runs as high as the lower lid. 

4. Transverse (Macrostoma), as a result of patency of the 

groove between the superior maxillary process and the first 
branchial arch (mandibula). 
Occasionally fistules and fissures are observed in the bridge of 
the nose and lower lip. 

For details of treatment the reader is referred to text-books 
on Surgery. 

CLEFT PALATE (PALATUM FISSUM, PALATOSCHISIS). 

It is due to defective union of the processes of the superior 
maxillary and palate bones which during intra-uterine life nor- 
mally grow inward to meet the vomer in the middle line and the 
intramaxillary bone in front to form the hard and soft palate. 



Surgical 
treatment. 



COXGEXITAL MALFORMATIONS OF FACE. 



129 



1. Complete (Uranoschisma). — The fissure extends in the mid- 
dle line through the uvula and the soft and hard palate, and 
thence through the alveolar process in the Hne of suture 
either on one or both sides of the intramaxillary bone. It 
is generally combined with double or single harelip, and is 
then designated "Wolf's Jaw." 



Wolfs 
jaw. 




Fig. 32.— Hare-lip. (Sheffield.) 



2. Partial (Uranocoloboma). — It may involve the UA^ula only, 
or part of the soft and hard palate as well. Sometimes it is 
limited to mere notching of the alveolar process on one or 
both sides and forms the continuation of uni- or bi-lateral 
harelip. 
The consequences of cleft palate, if extensive in degree, are 
by far more serious than those of cleft lip. Suction and deglu- 
tition are greatly interfered with. In older children the voice, 
articulation, sense of taste, smell, and hearing may all be impaired. 
The management of cleft palate is principally surgical. The 

9 



Difficult 
feeding. 



130 CONGENITAL MALFORMATIONS. 

earlier the operation is undertaken the more perfect are the 
operSfon^ resuUs. The mode of feeding frequently presents great diffi- 
culty. Infants born with marked cleft palate who are unable to 
nurse have to be fed artificially either with the spoon or through 
a tube passed through the nose into the stomach. A rubber plate 
covering the defect in the palate often acts admirably 

DEFECTS OF THE MOUTH AND TONGUE. 

Atresia Oris (Microstoma). — The lips may be grown 
together partially or completely. In the latter event an immediate 
plastic operation is inevitable. Congenital microstoma should not 
be confounded with the acquired contractures of the oral orifice 
resulting from syphilis, gangrene, burns, etc. 

Adhassio Linguae (Ankyloglossia, Tongue-tie). — It is pro- 
duced by a large and anteriorly displaced frenulum, and varies 
greatly in degree, the insertion of the frenulum sometimes extend- 
ing so far forward as to interfere with suckling and, later, with 
speech. 

The anomaly may be removed by nicking the frenulum with a 
scissors, and further ''loosening of the tongue-string" with the 
finger, thus avoiding injury to the ranine artery (dangerous in 
hemorrhage, hemophilia). The rare adhesion between the epithelial surfaces 
of the tongue and floor of the mouth can be liberated in a similar 
manner. 

Macroglossia (Large Tongue). — Enlargement of the tongue 
may be due to a true lymphangiomatous tumor (cavernous 
macroglossia), or to a fibrous hypertrophy (fibrous macroglos- 
sia). Both forms may coexist. The tongue may be so markedly 
enlarged as to find no room in the mouth, and by protruding from 
it become bruised, chapped and cracked, assume such dimensions 
as to render suckling very difficult or impossible, and possibly 
lead to a fatal issue from inanition. Congenital macroglossia 
tions^frim from the aforementioned causes is not to be mistaken for pro- 
cretinism. ^^^gj^j^ ^f ^^iQ tonguc associated with cretinism. Mild degrees 
of macroglossia usually improve spontaneously, with the growth 
of the oral cavity; severe forms call for removal of a wedge- 
shaped piece of the protruding tongue. 

MALFORMATIONS OF THE EYES. 

Anophthalmus (Absence of One or Both Eyes). — This is a 
rare malformation. In a great many cases careful anatomic 



CONGENITAL MALFORMATIONS OF FACE. 131 

examination reveals the presence of rudimentary eyes. If only 
one eye is absent the existing eye may be perfectly normal or 
defective in various ways. 

Microphthalmus. — An adbnormally small eye causes more 




Fig. 33. — Bilateral Anophthalmia. (Sheffield.) 

or less severe disturbance of vision which may in some instances Eyeglasses. 
be relieved by suitable glasses. It is sometimes associated with 
adhesion of the edges of the eyehds (ankyloblepharon, cryptopJi- 
thalmus), and other abnormalities of the bulb, which may require Sltmenl 
surgical treatment. 



132 CONGENITAL MALFORMATIONS. 

Atresia Pupillae Congenita. — Occasionally the pupillary mem- 
brane persists after birth and varying with its extent leads 
to more or less grave defective vision. The fine, gray membrane 
Differentia- may be mistaken for an exudation or capsular cataract. Spon- 

tion from -^ . . 

cataract, taneous unprovement is the rule. 

Cataracta Congenita. — It is usually partial, rarely complete.. 
It may exist in the form of limited opacities and not be recognized 
until school age. In the complete variety the condition may 
present a white pupil. 

Coloboma Iridis (Iridoschisma, Fissure of the Iris). — It is 
usually bilateral and sometimes associated with coloboma of the 
choroid, fissure of the upper eyelids without involvement of the 
external skin, microphthalmus, and cataract. If uncomplicated, 
it disturbs vision but slightly. 

Irideremia (Aniridia). — Partial or complete absence of the 
iris usually occurs on both sides and is associated with abnormal- 
ity of the cornea and poor vision. The pupils are iridescent like 
cats' eyes, and owing to too strong perception of light, the affected 
children convulsively open and close the eyelids. The same 
Albinism, phenomenon is often observed in albinism — a condition in which 
there is a congenital deficiency of pigment in the iris and choroid. 
Albinos have a blue iris and very fair complexion. 
^of^lgM^ Exclusion of superabundance of light by means of dark 
glasses or artificial diaphragm. 

MALFORMATIONS OF THE NOSE. 

Adhesions between the turbinated bones, particularly the 
inferior, and the septum. The adhesions may be membranous 
or bony, and not rarely associated with deflection of the 
septum. The treatment is the same as in the acquired 
conditions. 

Atresia of the Posterior Nares. — The closure may be mem- 
branous or bony; in the latter condition there is bony union 
between the palate and the sphenoid. If the closure is only 
moderately firm, it can be perforated by a stout probe or 
Difficult galvanocautery. Firm bony union giving rise to difficult suck- 
suckiing. \[^g (^.^llg fQj- j^i^Q employment of chisel and mallet or trephine, 
using the finger in the nasopharynx as a guide to prevent the 
instrument from penetrating too deeply. 



MALFORMATIONS OF LARYNX AND TRACHEA. 133 

MALFORMATIONS OF THE EAR. 

Fissures and Fistulas of the Ear. — Fissures (beneath the 
tail of the helix) and fistiilcs (in front and above the tragus) are 
occasionally observed, especially in connection with other con- 
genital malformations. Deep fistulse sometimes secrete a 
serous fluid, not rarely causing intractable eczema and requir- 
ing operative interference. 

Auricular appendages in the form of scattered round or 
oblong, smooth or warty pieces of cartilage are not rarely found 
in front of the ear. They can readily be removed by knife or 
cautery. 

Ear promixexce is a malformation which can often be 
remedied in the newly born by keeping the ear properly bandaged 
for several weeks. Sometimes it calls for a slight operation. 

Atresia auris, absence of the auditory meatus, is most fre- 
quently complete, involving the cartilaginous as well as the bony often 
portion of the canal. ^loreover there is usually also an abnormal tympanum. 
tympanic cavity. Hence A'ery little benefit can be expected 
from operative interference. 

All sorts of ear deformities are encountered in connection 
with idiocy and the allied mental deficiencies (q. z\). 



MALFORMATIONS OF THE LARYNX AND TRACHEA. 

Congenital Diaphragm of the Larynx. — The glottis is more 
or less occluded by a membrane running transversely across the 
vocal cords. The symptoms stand in direct relation to the size of 
the remaining opening. 

In marked cases the membrane should be excised after pre- 
liminary tracheotomy. 

Laryngocele and Tracheocele (Aerocele). — The tumor is 
situated laterallv or in the median line. It increases in size on 



Enlarges on 



coughing or crving and diminishes on pressure. crying or 

^ ^ ' . . . coughing. 

The treatment consists of excision of the cyst and closure of 
the communication with the respiratory tube. 

Stridor Congenitus (Child-crowing). — This congenital 
anomaly is not to be confounded with laryngospasmus 
(spasmus glottidis, see page 562). which is an acquired affec- 
tion and forms a symptom of spasmophilia (q. z\). 

The etiolog}^ is still indefinite, though in a number of cases the 



134 CONGENITAL MALFORMATIONS. 

stridor could be traced to malformation of the epiglottis and 
hypertrophy of the thymus gland. 

Stridor congenitus is manifested by a loud, crowing inspira- 
tion, accompanied by retraction of the jugulum and epigastrium, 
from It is free from cyanosis or any systemic disturbance, and usually 
subsides spontaneously in the course of a year or so. 



Free 

from 

cyanosis. 



MALFORMATIONS OF THE NECK. 

Fistula Colli Congenita. — It is a rare anomaly, the result 
of defective closure of the second and third branchial arches. 
The fistula is situated either laterally immediately above the 
sternoclavicular articulation or medially at a varying level be- 
tween the hyoid bone and the jugulum. The fistula becomes 
apparent by its fine, pinhead-sized opening with an irregular, 
moist surface. By passing a fine probe the fistula is found to 
end either blindly or in the pharynx or esophagus. As long as 
its track is free, the fistula gives rise to no serious symptoms. 
Its occlusion, however, is associated with danger of retention of 
the mucoid secretion and cyst formation. Hence the indication 
for complete extirpation of the fistulous canal. 

Branchial Appendages. — They occur in the shape of warts, 
nipples or mushrooms, along the margin of the sternomastoid, 
between the sternoclavicular region and the hyoid bone, consist 
of skin alone or of skin and cartilage, and are frequently asso- 
ciated with auricular attachments (q.v.). They cause no annoy- 
ance except from a cosmetic point of view. They are readliy 
removable and non-recurrent. 

Branchiogenetic Cysts. — The seat of these variously sized 
(from a small nut to a hen's egg), elastic, serous, seromucous, 
sebaceous, sometimes dermoid cysts is the anterior region of the 
neck (in the middle line or at the side). The cyst contents may 
iirfectfon. bccome purulcut through infection or sanguinolent through 
involvement of a blood-vessel. Aspiration is a useful aid in the 
diagnosis, and extirpation of the cyst the only rational mode of 
treatment. 

Hygroma Cysticum Colli Congenitum (Lymphangioma 
Cysticum). — This tumor consists of a number of small or large 
communicating or non-communicating cysts. It varies in size 
from a slight swelling under the lower jaw or over the clavicle 
to an enormous tumor embracing the whole neck, and extending 



MALFORMATIONS OF THORAX. 



135 



downward to the chest and upward to the face. It may even 
involve the mouth, throat, base of the cranium and mediastinum. 
In the latter event the prognosis is extremely grave. As the 
removal of large tumors is attended by great difficulties, it is 
often justifiable first to try aspiration with subsequent injection 
of iodine or incision and antiseptic packing. Small hygromas 
should unhesitatingly be extirpated. 

Cervical Rib. — The supernumerary rib is a hard, bony clasp 
which begins at the seventh cervical vertebra and either ends 
there as a small protuberance or continues farther to join 
the first thoracic rib, or even the sternum. The symptoms depend 
upon the degree of pressure exerted by the cervical rib upon the Pressure 

•11- • 1, 1 1 1 • 1 paralysis. 

neighbormg structures, especially the subclavian artery and some 
branches of the brachial plexus. 

Cervical rib may be confounded with exostosis of the first rib, 
tumor (also tuberculous g^lands) in the supraclavicular fossa, or Differentia- 

. . . . . . tion from 

cervical spondylitis. Exostosis and spondylitis are best diasrnosed exostosis or 

^ -^ ^ . . . spondylitis. 

by means of a careful X-ray examination. A tumor is softer and 
movable. 

In the event of marked disturbances the supernumerary rib 

^ -^ Resection. 

should be resected, care being taken not to injure the pleura. 



MALFORMATIONS OF THE THORAX. 

Defects of Sternum. — Partial or complete absence or smaller 
congenital clefts of the sternum are of rare occurrence. They 
give rise to hernial protrusions of the lung which if small in 
size are apt to be mistaken for soft tumors or abscesses. Lung 
hernia is reducible on pressure, changes in size and shape 
with respiration and is frequently associated with paroxysms of 
coughing. 

Among the divers deformities of the sternum, congenital, 
non-rachitic "funnel chest" is deserving of special mention. It 
differs from congenital or acquired rachitic funnel-shaped chest 
by the absence of other rachitic deformities. 

Anomalies of the Ribs. — One or more ribs may be absent 
or rudimentarily developed. The intervening space is filled with 
membrane. There may also be accessory ribs (see Cervical 
Rib), or several ribs may be united. 

Defects of the Thoracic Muscles. — Congenital, partial or 
total absence of one or several of the thoracic muscles is apt to 



Protrusion 
reducible 
on pressure. 



136 CONGENITAL MALFORMATIONS. 

^mvfscuilr ^^ mistaken for progressive muscular dystrophy. The former, 
dystrophy, however, is unilateral, while the latter is bilateral. Secondary 

scoliosis is apt to follow the congenital muscular defects. 

All the aforementioned malformations of the thorax require 

some mechanical contrivance, to prevent either injury to the 

internal structures or secondary deformities. 

MALFORMATIONS OF THE ALIMENTARY TRACT. 



Regurgitation 



Atresia CEsophagi. — Congenital esophageal strictures are 
very rare. They give rise to difficulty of swallowing and 
of food, immediate regurgitation of the food through the mouth and 
nose. 

The treatment is the same as in acquired esophageal strict- 
ures. Owing to the absence of true scar tissue in the congenital 
form, the prospects of recovery are brighter. 

STENOSIS PYLORI CONGENITA. 

Stenosis of the pylorus may be complete or partial. Complete 
atresia is extremely rare and invariably fatal within a few days 
after birth — before the diagnosis can be established. 

Partial stenosis of the pylorus, on the other hand, is a com- 
paratively frequent affection which not rarely terminates in re- 
covery, either spontaneously or through medical and surgical 
treatment. It is distinguishable in two forms : True and False. 

1. True or hypertrophic pyloric stenosis is invariably due to 
narrowing. ^ Congenital narrowing of the lumen of the pylorus and is asso- 
ciated with more or less primary hypertrophy of the pyloric ring. 

2. False or spastic pyloric stenosis (pylorospasm) is the result 
of congenital faulty innervation of the stomach, or of acquired 
digestive and nervous disturbances. It is free from primary 

Spasmodic hypertrophy of the pyloric ring. Sooner or later secondary 
hypertrophy of the muscular and mucous coats of the stomach 
occurs in consequence of the increased force required by the 
stomach to propel the ingesta. At a later stage of the disease the 
stomach walls lose their tonicity and dilatation is a frequent 
complication. 

The diagnosis of true pyloric stenosis usually presents no 
difficulty, and it can readily be distinguished from atresia of the 
esophagus or duodenum by bearing in mind the typical clinical 
picture of the disease. The apparently fully developed infant at 



Organic 



contraction. 



MALFORMATIONS OF ALIMENTARY TRACT. 187 

birth, after a period of well-being of from a half to three weeks, 
begins to vomit sometime after each feeding. The vomiting 
rapidly becomes very violent in character, and the contents of 
the stomach, which appear greater {iscIwcJiyniia — retention of y^^ltSg^ 
digested food) than the child could have taken in one feedinsf remnants 

o - c5 of previous 

and consists of a hyperacid^ mixture of mucus, digested and un- feedings. 
digested food, free from bile, is explosively ejected. As an im- 
mediate result of the vomiting, the intestinal tract remains empty ; 
hence, pseudoconstipation or only occasional evacuation of a 
small quantity of brown, foul-smelling fluid. The urine is scanty ^^^3^^^^ ^f 
and concentrated. The infant acts very hungry, voraciously ^"J^^lments 
swallows a few mouthfuls of food, but. being seized by sudden 
spasmodic pain, drops bottle or breast, only to grasp it again 
after some relief prevails. The abdom.en is sunken in, while the 
epigastrium is distended, and here and there are visible peristaltic peristalsis, 
movements { Jiypcrki)icsis ) of the stomach, from right to left. 
In some cases a tumor — the hypertrophied pylorus — is palpable 
a little to the right of the stomach and in cases of long standing 
there is usually more or less marked gastric dilatation. 

In pylorospasm the symptoms are much less pronounced, but 
otherwise cannot be distinguished from true pyloric stenosis. 
The course of the affection A'aries Avith the degree of the con- 
tracture. In the majority of instances the true form of the dis- 
ease, if not operated upon early, terminates fatally in from four 
weeks to four months, with symptoms of inanition and collapse, bad^with 
Occasionally, however, a change for the better occurs and slow opel-auon. 
recovery folloAvs. This is particularly apt to take place in spastic 
pyloric stenosis, especially if early and properly treated. With 
these facts in view, it is extremely difficult to decide when, and 
whether, surgical intervention is indicated. The profession is 
greatly divided on this question. The statistics adduced for and 
against an operation seem to favor both contentions. The surgi- 
cal ''cures'' do not always assure us of their permanency.- On 
the other hand, who can A'ouch for the permanency (remissions 
are not rare!) of the medicinal "cures," and for the correctness 
of the diagnosis in such cases ! Appreciating, then, the gravity 
of the prognosis of true pyloric stenosis even under the best 
medical management, and the recent grand achievment in stomach 



1 In one case under our observation there was total achylia gastrica. 

- A little patient of mine, nine weeks old, recently operated upon, did 
well for six days, but died two days later from the effects of a minute 
gastrointestinal fistula. 



138 CONGENITAL MALFORMATIONS. 

surgery, it is justifiable after two zueeks' faithful but unsuccessful 
trial of dietetic and medicinal measures to recommend an opera- 
tion, namely: — 

1. In bottle-ied infants presenting the usual symptoms of 
pyloric stenosis, plus pylorus-tumor. 

2. In breast-itd infants presenting the usual symptoms of 
pyloric stenosis, even minus palpable pylorus-tumor. 

j,^^j An operation, if indicated, should not be delayed until the 

operation child is at death's door. The choice between divulsion (Loreta's), 

m true ^ ^ ' 

stenosis, pyloroplasty and gastroenterostomy depends upon the patho- 
logical condition of each individual case. 

The non-suvgicsil treatment of congenital pyloric stenosis 
must be carried out systematically and faithfully. Whenever 
possible, the infant should be fed on woman's milk, preferably 
with a spoon or tube, in order to gauge the amount of food con- 
sumed and possibly retained by the infant. The amount of 
feeli^gs^ ^^^^ feeding should not exceed one ounce, but may be given 
every hour, so as to sustain the child's vitality. Modified or pre- 
digested milk may be administered instead of woman's milk if 
the latter is not readily obtainable. In view of the fact that 
almost two-thirds of the cases of pyloric stenosis thus far re- 
ported were breast-fed babies, one is tempted to recommend 
cows' milk feeding as a therapeutic or, at least, prophylactic 
measure against pyloric stenosis. Indeed, following the tempta- 
tion in one of my own cases I was — perhaps accidentally — re- 
warded by happy results. May I venture to suggest that the large 
curd of cows' milk tends mechanically to dilate the contracted 
pyloric orifice? 

Reduction in the frequency of the attacks of vomiting and in 
the amount ejected forms the first and best indication of im- 
provement in the condition. Next to careful feeding, systematic 
washing of the child's stomach serves as the sheet-anchor in the 
Lavage, therapcusis of congenital pyloric stenosis. It should be prac- 
ticed at least twice a day with plain, cool (6o° to 70° F.) water, 
occasionally adding a small amount of bicarbonate of soda to 
neutralize the hyperacidity of the stomach. The washing should 
be continued until the water returns clear. The efifects of the 
lavage are the removal of decomposing substances from the 
stomach, arrest of fermentation and allayment of pain and 
spasm. For the latter purposes prolonged warm baths and hot 



poultices 



^°^ compresses to the epigastric region are also very useful. To 



MALFORMATIONS OF ALIMENTARY TRACT. 139 

counteract the excessive loss of fluids, a daily enteroclysis or 
hypodermoclysis is of advantage. Internal medication is of 
little value except anodynes for the relief of pain and spasm. Anodynes. 
For this purpose minute doses of codeine with or without bella- 
donna may be administered in the form of suppositories. 

Skillful nursing privately or in hospital should be insisted 
upon. 

CONGENITAL STENOSES AND ATRESIA OF THE 
INTESTINES. 

Any portion of the intestines may be congenitally malformed 
or completely obliterated. Partial stenosis is most frequently 
observed in the small intestine, while complete atresia in the 
rectum and anus. As in acquired intestinal obstruction, the 
lumen of the intestine above the occlusion is widely dilated, while 
that below it is more or less collapsed. 

The symptoms vary with the seat of the lesion. The higher 
the stenosis, the earlier and more pronounced the vomiting, the 
larger the quantity of the meconium, and the more marked the 
dyspnea and eventually the cyanosis as a result of compression 
of the thoracic organs by the highly distended stomach. 

On the other hand, the lower the stenosis, the more fecal the Fecai 
vomiting, the greater the meteorism, and the more marked the meteorism 
disturbances of the bladder and kidney (partial or total anuria 
as a result of compression of the ureters by the highly distended 
intestines). In stenosis of the duodenum the vomitus contains 
bile substances. 

Associated with the local symptoms of intestinal stenosis 
are : dry tongue, subnormal temperature, rapid emaciation, complete 
pinched features of the face, and collapse. Death usually takes fatal, 
place within a week. \Miere the stenosis is only partial and 
slight, the child may linger for months and ultimately recover. 

In mild cases the treatment should be symptomatic, princi- 
pally to relieve constipation and to mitigate the pain and agony. 
Surgical intervention as a last resort. 

CONGENITAL HYPERTROPHY AND DILATATION OF 
THE COLON. 

(Megacolon Congenitum, Hirschsprung's Disease). 

This congenital aftection should not be mistaken for acquired 
dilatation of the large bowel associated with intestinal atony 
from various causes. 



Operation. 



140 



CONGENITAL MALFORMATIONS. 



Greatly 
distended 
abdomen. 



Constipation 

alternating 

with 

diarrhea. 



findings. 



The congenital dilatation is manifested soon after birth by 
retention of the meconium, although the child is otherwise ap- 
parently healthy and free from congenital stenosis of the anus 

or rectum. Intestinal irri- 
gation brings forth but a 
small quantity of feces. 
The infant is restless and 
constipated, and its abdo- 
men gradually becomes 
greatly distended. Some 
time later the constipation 
is followed by more or less 
copious diarrhea due to 
irritation from retained 
feces. After expulsion of 
the stool and gases the 
abdomen is reduced in size, 
but after a short time it 
again becomes distended, 
giving rise to the afore- 
mentioned symptoms. Most 
infants succumb early to 
the disease, from inter- 
ference with the thoracic 
organs or autointoxication 
by the decomposing intes- 
tinal contents ; others may 
live longer and in rare in- 
stances even entirely re- 
cover. 

Post-mortem examina- 
tion reveals either of the 
following conditions : — 

1. Simple dilatation and 
often lengthening of the 
colon ; 2, ectasis of a section 
of the colon with or with^ 
out compensating dilata- 
tion or hypertrophy of the adjoining portions; 3, general 
enlargement of the intestinal lumen and hypertrophy of its walls. 
The hypertrophy usually involves the longitudinal and circular 
muscular fibers. 




Fig. 34. — Megacolon Congenitum 
Pathologic years old). The size of the abdo- 
men is considerably reduced after high 
enema. {Sheffield.) 



MALFORMATIONS OF ALIMENTARY TRACT. 141 

The treatment is chiefly symptomatic (see Constipation). f^'^F^^^^^^ 
In severe cases surreal intervention. eventually 

•^ operation. 

ATRESIA OF THE RECTUM AND ANUS. 

(a) Atresia Ani Proper (Imperforate Anus). — The rectum 
is normal and ends bhndly into the completely closed anus. 



h. J^^^ 


^ 1 




^^P 


1 ^ 


^4 


j^^^^KMm. 


jH 



Fig. 35. — Congenital Absence of Scrotum and its Contents, 
Anus and Rectum. (Sheffield.) 

There may not be the slightest indication of an anus, or the 
latter is indicated by a few comb-like prominences, a small fossa, 
or a round induration. 

(b) Atresia Recti. — The anus is normally developed, but 
the rectum ends blindly somewhere higher up in the canal. 

(c) Atresia Ani et Intestini Recti. — In this condition the 
anal orifice is absent and the rectum is arrested in its develop- 
ment higher up, usually in the region of the sacroiliac symphysis. 



142 



CONGENITAL MALFORMATIONS. 



(d) Atresia Ani Complicata. — There is atresia of the anus, 
and the rectum terminates either (1) in the bladder (atresia recti 
vesicahs) ; (2) in the vagina (atresia recti vaginalis), or some- 
where in the urethra (atresia recti urethralis). 

(e) Atresia Recti cum Fistula. — The anus proper is 
occluded ; the rectum ends blindly, but is connected with the 




Stomach 



Blind]"pouch 



Fig. 36.— Stomach and Intestines of case Fig. 35, showing ending 
of colon in a blind pouch filled with meconium. (Sheffield.) 



outer skin by a fistulous tract. The anal orifice is thus located 

in an abnormal position in the perineum, vulva, scrotum, etc. 
The diagnosis of imperforate anus or rectum usually presents 

no difficulty. Imperforate anus can readily be made out by 
Absence of inspection. Absence of meconium in the presence of a normal 
meconium, ^j^^g indicates that the defect is somewhere higher up. Digital 

or instrumental examination rarelv fails to locate the seat of 



MALFORMATIOXS OF ALIMENTARY TRACT. 143 

obstruction. Atresia ani complicata may be detected by the 
presence of meconium in the urine or by continuous escape of Meconium 
feces from the abnormal communications. The latter symptom IJl-ine. 
is indicative also of the last form (^) of atresia, which can readily 
be seen. 

Imperforate anus and imperforate rectum are the only two 
conditions giving rise to immediate more or less grave symp- 
toms. The child passes no meconium, appears restless, strains, 

11 • 1 • 1 1 • rr r i i Symptoms 

cries, its abdomen is distended, it suiiers irom dyspnea, and of 

1, -r r 1- 1 • 1 • 1 • obstruction. 

vomits occasionally, if not relieved it succumbs witnm a 
week from rupture of the intestines and peritonitis. Prompt 




ve 
treatment. 



Fig. Zl . — Diastasis Recti Abdominis Patient suffering also from 
amaurotic famil}^ idiocy. (Sheffield.) 

Operative interference is therefore imperative. If the obstruc- 
tion is in the anus, or in the low^er part of the rectum, puncture 
or incision with consecutii^e dilatation will often suffice to effect 
a cure. Whenever the point of the atresia cannot be discerned, p^^^^^J 
an artificial anus should be made for quick relief, postponing 
the curative measures for later. An operation should be post- 
poned also in all other forms of atresia ani or recti, where the 
escape of meconium is not entirely interfered Avith. 

DEFECTS OF THE ABDOMINAL PARIETES. 

Diastasis Recti Abdominis. — Lozenge-shaped separation of 
the abdominal wall extending from the xiphoid to the umbilicus 
is congenital in nature and due to defective closure of the deep 
layers of the abdominal coverings. It is sometimes associated 
with umbilical hernia. 



144 



CONGENITAL MALFORMATIONS. 



colic. 



The symptoms make their appearance when the child is able 

Sudden to run about and jump, and consist of sudden attacks of colic 

(not to be mistaken for enteralgia !), uneasiness in the epigastric 

region, pallor, etc., which subside when the child is perfectly at 

rest. These paroxysms are due to partial incarceration of the 




Fig. 38.— Umbilical Hernia. (Sheffield.) 

stomach in the abdominal slit, and should be remedied by bring- 
Abdominai i^g and keeping the separated recti muscles together by means 
of plaster straps or suitable bandage. 



CONGENITAL UMBILICAL HERNIA. 

(Hernia Funiculi Umbilicalis, Exomphalos, Omphalocele 

Congenita, Ectopia Viscerum, Amnion Navel). 

As a result of faulty development of the abdominal cover- 
ings, instead of an umbilicus, a variously sized, sacHke dilata- 



MALFORMATIONS OF ALIMENTARY TRACT. 



145 



tion is occasionally observed which may contain intestinal loops, 
the stomach, liver, spleen, etc. The hernial sac is composed of 
the amnion and parietal peritoneum. At birth the contents of 

. . Small 

the sac can usually be recos^nized throug^h the thin, transparent protrusions 

. may be 

membranes, but small protrusions into the cord are apt to be overlooked 




Fig. 39. — Thoracoabdominopagus, with Ectopia Viscerum. 
(Sheffield.) 



overlooked, and carelessly tied off with the umbilical rest. If 
there is considerable eventration, the infants die early from 
rupture of the sac and peritonitis. The first indication there- 
fore is to replace the prolapsed structures into the abdominal 
cavity and to keep them there by means of a suitable bandage. 

10 



Reposition 
of prolapsed 
portion, and 
strapping. 



146 



CONGENITAL MALFORMATIONS. 



Radical In this manner small hernias not rarely subside spontaneously, 
operation. L^j.gg hernias should be treated by a radical operation. 

PERSISTENCE OF THE DUCTUS OMPHALO- 

MESENTERICUS. 

(Vitellointestinal Duct). 

Physiologically, the omphaloentericus duct, the embryonic 
tubular communication between the intestinal canal and the 




Fig. 40. — Skiagram of Thoracoabdominopagus (same as Fig. 
39), with Ectopia Viscerum. {Sheffield.) 



germinal vesicle, disappears at about the eighth week of fetal 
life. Occasionally the duct is not obliterated, and leads to the 
following principal abnormalities : — 

1. A fine fistula at the umbilical ring, forming a communica- 



MALFORMATIONS OF ALIMENTARY TRACT. 147 

tion between the bowels and the exterior, and secreting a cloudy 
fluid containing a trace of fecal matter. 

2. A hernial protrusion through the umbilicus in the form 
of a red finger-shaped tumor which is usually composed of the 
prolapsed walls of the fistula, but sometimes is composed of 
intestinal loops. 

3. Open Meckel's diverticulum. It is a blind appendage of 
the lower part of the ileum, and may be free or united with the 
umbilicus by a solid cord. Under certain conditions it may enter Danger of 

a hernial sac and here become strangulated. It may produce strangulation, 
"ileus" by incarcerating some loops of the intestines, and give 
rise to local intestinal inflammation closely resembling that of 
appendicitis. 

Persistent omphaloenteric duct mav be mistaken for : — 

1 -n • 1 ^ • ' • -11 1 Differentia- 

1. rersistent urachus. On exammation with the catheter tion from 

persistent 

It can be reached throus^h the bladder ; the secretion is urachus, 

and 

composed chiefly of urine. sarcomphaios. 

2. Sarcomphaios — has no fistular opening. 

Fine fistulse frequently close after repeated cauterization with 
the caustic stick. Wherever the prolapse is very marked or in 
cases associated with open diverticula a radical operation is 
imperative, since their presence is always a menace to life. 

URACHUS FISTULA. 
(Fissura Vesicae Umbilicalis). 

Persistent urachus — the duct through which the urinary blad- 
der communicates with the allantois — gives rise to a fistulous 
tract which ends at the umbilicus. On pressure a small hernial 
tumor arches forward and secretes a clear or turbid fluid, com- Escape of 
posed of urine alone, or urine, mucus and pus. If the fistula is Ji^rough 
large, the flow may be continuous. It may give rise to cystitis and 
even pyelonephritis compelling early operative procedures. The 
first attempt at a cure should be directed to making the natural 
outlet quite free (e.g., cure of phimosis). Small fistul^e often 
yield to cauterization and continued pressure with a bandage. 
If this fails, the Avails of the sinus should be freshened and 
then sutured. 

Its differentiation from persistent ductus omphalomesenteri- 
cus has been emphasized above. 



urine 
throu? 
umbilicus. 



148 



CONGENITAL MALFORMATIONS. 



MALFORMATIONS OF THE GENITO-URINARY 

ORGANS. 
CONGENITAL ABNORMALITIES OF THE KIDNEYS. 

The kidneys, like all other parts of the body, are subject to 
Deformity, defective embryonic development. They may be abnormal in 
size, shape (horseshoe) and number. This is of clinical impor- 
tance, since malformed kidneys are more easily affected by dis- 
ease, especially tuberculosis, than normal organs. Congenital 
Absence, absence of one kidney has been observed once in about 4000 
autopsies. Furthermore, it is usually found that, whenever one 
kidney is absent, the other one is in a more or less diseased con- 
Dispiacement. ditiou, chiefly greatly hypertrophied. Congenital displacement 
of the kidney (both kidneys on one side; in front of the verte- 
bral column; low down in the pelvis) is very apt to cause many 
diagnostic errors. 

MALFORMATIONS OF THE URETERS. 

Abnormal ureteral openings, as to size and position, are 
of great clinical significance. In the male the ureter may termi- 
nate into the sphincter of the bladder, the prostatic portion of the 
urethra, or in the seminal vesicle, and by interference with the 
Secondary flow of uriuc givc risc to dilatation of the ureter and renal 
of kidneys, pelvis and atrophy of the renal parenchyma. In the female the 
ureter may end in the sphincter of the bladder, in the urethra, 
or in the vagina. More serious than misplacement is absence or 
atresia of the ureter. Either one of these latter conditions in- 
variably produces hydronephrosis, compelling extirpation of the 
affected kidney. Double ureter, if free from any other anomaly, 
is not attended by any pathologic phenomena. 



MALFORMATIONS OF THE BLADDER. 

Ectopia Vesicae Congenita, Cleft Bladder, Fissure of the 

Bladder, Exstrophy Vesicae. — Cleft bladder arises from arrest 

of development of the anterior walls of the bladder and 

abdomen, and often also of the symphysis. It may be partial 

Round o^ complete. In the complete variety the posterior vesical 

red m°ass ^'^'^^^ protrudcs as a round, moist, bright-red tumor, through a 

gastrfum' §"^P ^^ ^^^ abdominal wall, situated in the median line between 

the umbilicus and the urethra. The mass is marked by two 

small tubercles on both sides — the orifices of the urethra — 



MALFORMATIOXS OF GEXITO-URIXARY ORGANS. 149 

from which the urine dribbles continuously. In the male this 
is associated with epispadias of the rudimentary penis; in the 
female the clitoris is clefted, the labia are widely separated, 
and the urethra and vagina more or less defective. Eversion prognosis 
of the bladder is often complicated also by other malformations 
of the body, and in majority of instances leads to early death. 
Partial ectopia vesica otters a more favorable prognosis, par- 
ticularly if a plastic operation is resorted to early. Temporary 
relief may be obtained from a suitable urinal held in place by 
means of a truss. 

MALFORMATIONS OF THE URETHRA, PREPUCE, 
TESTICLES, AND VAGINA. 

Atresia Urethras. — Total atresia iirctJirct is a rare malforma- 
tion. AMien it does occur, it is usually epithelial in nature or 
at most membranous. In the former instance the atresia 
promptly yields to pressure with the tip of a sound, in the ^^^'^i^io^- 
latter to a small incision and dilatation by means of a small, 
blunt silver probe. 

Co}}iplctc absoicc of the urethra is extraordinarily rare. 

CoJigoiital stowscs are not rarely found along the urethra, 
and if presenting no distinct hindrance to urination are fre- 
quently overlooked. 

In cases of marked urethral stenosis, the still patent urachus 
often permits the escape of urine through its fistulous tract 
running from the bladder to the umbilicus. 

Misplacement of the Urethral Opening (Epispadias, Hypo- 
spadias). — The urethral opening may be situated on the upper 
part of the penis ( epispadias i or at its inferior aspect (hypospa- 
dias L The latter abnormalit}- is more frequent than the former. 
Both conditions are productive of more or less disturbance of incontinence; 
urination (incontinence in epispadias: dysuria in hypospadias^. '^ 
secondary intertrigo, erosion and ulceration of the genitalia from 
the effects of the irritating urine, and later in life interference 
with virility. 

Pronounced hypospadias fperineoscrotar) closely resembles 
hermaphroditism, and when it is associated with retention of 
the testicles it may be impossible to determine the sex of the 
infant. 

Except in the very mildest cases early operative interference operative 

Is indispensable. ' ' treatment. 



150 CONGENITAL MALFORMATIONS. 



CONGENITAL PHIMOSIS. 

A moderate degree of adherence of the prepuce to the glans 
penis is physiologic in the newborn. Ordinarily the adhesions 
disappear spontaneously in the course of time. In some cases, 
however, the prepuce remains adherent and stenosed at its orifice 
so that the glans cannot pass through. In consequence there is 
more or less retention of urine between glans and prepuce (par- 
ticularly if the latter is elongated or hypertrophied), infection 
and decomposition of the sebaceous secretion (smegma), and 
secondary inflammation of the penis and adjacent structures. 

In the presence of inflammation urination is difficult and 
Dysuria. ^cry paiuful ; the infant cries, presses and strains (in predis- 
^o^urinT P^^cd children often the cause of hydrocele, hernias and prolap- 
sus recti), or fearing pain retains the urine for many hours, 
a habit which is apt to give rise to cystitis, pyehtis, and even 
uremic convulsions. 

Phimosis frequently forms also the cause of enuresis, pria- 
pism, masturbation, and a number of more or less reflex nervous 
phenomena. 

In mild cases of phimosis the prepuce should frequently be 
pushed back and forth and the retained smegma removed. 
Where the adhesions are very firm they may be broken up with 
the aid of a dull probe and kept loose by daily pulling back the 
foreskin and applying an antiseptic cooling lotion such as lead- 
water or a 2 per cent, solution of aluminium acetico-tartrate. 
In this manner good results are obtained within a few days. 

Where the preputial stenosis is the predominating trouble, 
iiSfsfons slight nicking of the preputial ring with a scissors (laterally, 
looserdSg above, and below), followed as before by loosening of the adhe- 
of prepuce, gions, daily preputial retraction and local antiphlogosis, is all 
that will be necessary to effect a permanent cure. This pro- 
cedure is at all times preferable to circumcision, except in cases 
of phimosis associated with elongated or greatly hypertrophied 
foreskin and severe inflammation. 

Circumcision, when indicated, should be performed under 
very careful aseptic precautions, preferably under general anes- 
thesia. The surgeon grasps the prepuce between the thumb and 
index finger, exerting sufficient traction to draw it from the 
glans penis, puts over it a shield or forceps just in front of the 
glans, and with scissors or knife removes the distal, superfluous 



MALFORMATIONS OF GENITO-URINARY ORGANS. 151 

portion of the prepuce. He next seizes the inner layer of the 
prepuce, which still covers the glans, with a thumb forceps and 
with the aid of a scissors cuts it so far backward as to enable 
him fully to expose the glans and bring the edges of both pre- 
putial layers in apposition by a fine continuous suture. The Danger of 
dressing should consist of sterile gauze (not medicated! danger andhemor-' 
of intoxication). Numerous accidents have been reported as the ^ ^^^' 
result of circumcision, but all, except uncontrollable hemorrhage 
in the hemophilic, are preventable. In such hemorrhage the 
actual cautery should be resorted to without delay. Milder 
hemorrhages will often yield to firm compression of the penis 
with a hard catheter in the urethral canal. 

CRYPTORCHIDISM. 
(Undescended Testicles). 

Normally the testicles descend into the scrotum by the end of 
fetal life. In the event of a constriction of the inguinal ring, and 
malformation of the testis, epididymis, or the vas deferens, etc., 
one (monorchidism) or both {cryptorchidism) testicles are not 
infrequently retained in the abdominal cavity, at the inguinal ring, 
or at the upper portion of the scrotum. More rarely the testicles 
become displaced, and through a false passage emerge either at 
the crural arch (crural testicle) ; under the fold of skin between 
the thigh and scrotum (scrotofemoral testicle) ; or behind the 
scrotum (perineal testicle). 

In the majority of instances an undescended testicle is free 
from any serious consequences, and reaches its normal position 
spontaneously within the first few years of life. Occasionally, Spontaneous 
however, it may become impacted at the inguinal canal, giving 
rise to excruciating pain and inflammatory symptoms ; if asso- 
ciated with a hernia, strangulation may take place in both struc- stranguia- 
tures at the same time; it may cause atrophy of the genitalia; 
it may be the seat of malignant degeneration, and, finally, it 
may be productive of a number of reflex phenomena (epilepsy?), ^mptoms. 

Cryptorchidism should not be confounded with anorchidism 
or absence from the body of both testicles (is usually associated 
with rudimentary penis and, later, absence of spermatic secre- 
tion), or with ascent of the testicles from contraction of the 
scrotum (they descend with relaxation of scrotum). 

Expectant plan of treatment up to puberty in the absence of 
complications. Capsular truss in cases of misplacement. Gentle 



152 CONGENITAL MALFORMATIONS. 

massage is useful. Orchidopexy and other surgical procedures 
as indications arise. Speedy operation in case of strangulation. 

HYDROCELE. 

It is a common affection of early infancy and most frequently 
congenital in nature. Varying with the seat of the accumulation 




Fig. 41. — Congenital Hydrocele, Commnnicans. (Sheffield.) 

of the abnormal quantity of serous fluid, we distinguish the fol- 
lowing kinds : — 

1. Hydrocele Tunic cc Vaginalis. It is a unilateral, oval,. 
Swelling smooth, trausluccnt, more or less tense, fluctuatins: swellins:, 

at lower ' ' ' o a' 

sc?otim^ which appears first at the lower part of the scrotum, and grad- 
ually rises up to the abdominal ring. Posteriorly to the hydrocele 
usually lies the testicle. 



MALFORMATIONS OF GEXITO-URIXARY ORGANS. 153 

2. Hydrocele Fiuiiculi Spermatid {hydrocele of the cord), 
resembles the former, except that the testicle usually Hes at the separated 
bottom of the scrotum and is distinctly separated from the tSucie 
hydrocele by a constriction. It is sometimes made up of several constriction. 
small cysts simulating a string of beads. 

3. Hydrocele J^agiiialis Co^Jiiniiiiicaiis ("CoJigenital Hydro- 
cele''). This form occurs when the tunica vaginalis preserves 
its communication with the abdominal cavity and becomes filled 
with serum, forming a cylindrical tumor, extending to and 
through the abdominal ring. It is often associated with hernia with hernia, 
(hydrocele hernialis). As the contents of both are reducible on 
pressure the diii'erential diagnosis between congenital hernia and 
hydrocele vaginalis communicans is sometimes difficult. In 
hydrocele, however, the return of fluid to the peritoneal cavity 

occurs without intestinal gurgling — the reverse being the case in 
congenital hernia. 

Hydrocele often disappears spontaneously, especially after 
removal of reflex irritation, e.g., phimosis. If it persists, we 
employ local counterirritation ( painting with tincture of iodin or 
mercury ointment), or aspiration, if the hydrocele enlarges. The 
latter procedure may be followed by the injection of a few drops 
of equal parts of tincture of iodin or carbolic acid and alcohol. 
Absorption of the fluid is hastened by a few large doses of 
potassium iodid. In hydrocele communicans a truss should be Truss. 
worn to prevent hernia. The pressure exerted will often oblit- 
erate the inguinal portion of the vaginal process, and also cure 
the hernia, if present. 

If the aforementioned palliatiAX and curative measures fail — 
which is rarelv the case — a radical operation becomes necessarv. Radical 

^ • operation. 

Atresia Vulvas. — It consists chiefly of a cellular adhesion of 
the labia minora, and may be partial or complete. In total 
atresia vulvae there is anuria. Avith its secondary symptoms, 
necessitating immediate attention, i.e., forcible separation of the 
labia with the fingers or with the aid of a dull sound or scalpel. 
In partial atresia separation of the labia occurs spontaneously. 

Atresia Vaginae Hymenalis (Imperforate Hymen). — This 
congenital malformation usually escapes observation until pu- 
berty, when partial or total retention of the menstrual flow gives 
rise to local and general disturbances. 

Incision and packing with iodoform gauze readily remedies 
the trouble. 



Counter- 
irritation. 



Filled with 



154 CONGENITAL MALFORMATIONS. 

Atresia Vaginas. — Like the aforementioned malformation, 
narrowing or complete closure of the vagina is not detected until 
after puberty. Total atresia vaginae is usually associated with 
absence of the uterus. This should always be borne in mind 
before resorting to operative procedures for the relief of the 
atresia. 

CONGENITAL MALFORMATIONS OF THE 
VERTEBRAL COLUMN 

(Including those of the Sacrum and Coccyx). 

SPINA BIFIDA (HERNIA OF THE CORD). 

Meningocele Spinalis, Myelocystocele, Myelomeningocele. 

— Analogous to hernia of the brain (see "Cephalocele"), that of 
the cord also is divisible in three principal groups : Menin- 
gocele spinalis, myelocystocele, and myelomeningocele. 

(a) Meningocele spinaHs is a protrusion of the pia mater 
without participation of the spinal cord. It is filled with cere- 

^^r^na'i brospinal fluid, translucent, often pedunculated and may reach 
fi^i'i- the size of a child's head. It is covered by normal skin. Paral- 
ysis is rare. Pressure on the tumor produces bulging of the 
fontanelles and spasms. 

(b) Myelocystocele is situated on a broad base and is readily 
replaceable on pressure. The covering skin is greatly distended 

Solid ^^^ normal in color. Palpation reveals that the tumor consists 
of solid masses in addition to fluid. It is frequently associated 
with hydrocephalus and accompanied by motor and sensory 
disturbances. 

(c) Myelomeningocele is a pear-shaped or spherical, fluctuat- 
ing, tense, broad or pedunculated tumor the size of a walnut to 
that of a child's head. Its covering skin is bluish, very thin and 
traversed by numerous blood-vessels. It is composed of cord 

^^S^tl substance and its membranes and forms a true hernial protrusion 

membranes, through a clcft in the vertebral column. The cleft and to some 

extent also the hernial orifice can often be felt at the base of the 

tumor. Myelomeningocele is the most frequent variety of spina 

bifida and gives rise to marked motor and sensory paralyses. 

Almost all forms of spina bifida are associated with hyper- 
trichosis of the surrounding skin. This is especially pronounced, 
and indeed, often forming the only outward sign of deformity, 
in spina bifida occulta (a meningocele usually of the sacrolumbar 
region hidden under masses of fat). The hair is usually so 



masses 
and fluid. 



Cord 



MALFORMATIOXS OF VERTEBRAL COLUMN. 



lo3 



arranged as to form a crown over the center of the defect. 
When well developed it may resemble a tail. 

Apart from the malformation the condition of most children 
at first is perfectly normal. As the tnmor enlarges the results 
of the pressure on the cord or the cauda equina gradually ap- 
pear. The symptoms vary with the degree of involvement of symptoms, 
the spinal cord; they 
are. therefore, most pro- 
nounced in myelomenin- 
gocele sacrolumbalis. 
TIere we haA'e motor and 
sensory paralyses of the 
legs, of the rectum, blad- 
der, and the perineal 
muscles, convulsions and 
trophic disturbances. In 
less severe cases, the 
paralysis may be limited 
to the legs only. 

Bearing in mind the 
characteristic symptoma- 
tology of spina bilida, i.e., 
a more or less translu- 
cent, compressible, barelv 
movable, thinly covered 
tumor, in the majoritv of 
instances associated with 
paralyses, there ought to 
be no difficulty in differ- 
entiating it from sacro- 
lumbar neoplasms. In 
cases of doubt the diag- 
nosis may often be cleared 

up by exploratory puncture and radiographic examination 
(^the latter showing a vertebral cleftj. 

Spina bihda may sometimes escape notice when it is sur- 
rounded by a solid tumor. 

The majority of children with marked spina bifida die when 
very young, often during birth, owing to rupture of the tumor 
and shock following rapid escape of the cerebrospinal fluid, 
^lost of those who survive succumb later from rupture of the 




Differentia- 
tion from 
neoplasms. 



Fig. 42. — Spina Bifida in a boy 
8 A-ears old. 



156 CONGENITAL MALFORMATIONS. 

sac and subsequent infection and purulent meningitis ; from 

gangrene and ulceration of the skin with subsequent sepsis ; and 

finally, from intercurrent diseases and marasmus. Simple 

^°againJt meningocele gives the best prognosis if recognized early and 

injury. pj.Q^g(>|-g(^ from external insults by a suitable pad or apparatus. 

This palliative method of treatment should always be tried in 
cases of spina bifida that project very slightly and are covered 
by normal, well-nourished skin. Aspiration of the hernial sac 
is useful to relieve the symptoms of compression and to lessen 
the danger of spontaneous rupture. Aspiration may be followed 
by injection of iodin or preferably iodin-gelatin. In selected 
cases it may prove of permanent benefit. 

Radical operation is the ideal procedure in suitable cases. 
Radical Howcvcr, cxtcnsivc paralyses, severe irreparable malformations 
elsewhere, hydrocephalus, and grave systemic affections are con- 
traindications to operation. In such cases palliative and symp- 
tomatic methods of treatment are indicated. 



CONGENITAL SACRAL TUMORS. 

Closely related to and frequently associated with spina bifida 
(q.v.) are congenital sacral tumors. They may be classified as 
follows : — 

1. Double Formations — 

(a) Complete — two fully formed individuals grown 
together at the buttocks. 

(b) Incomplete or parasitic formations — one or several 
rudimentary portions of the body attached to the 
buttocks of a fully formed individual. 

2. Sacral Hygromas. — Single or multiple cysts, attached by 

a broad base to the dorsal surface of the sacrum. 
They are sometimes associated with spinal hernia. 

3. Tumores Coccygei. — Neoplasms attached to the anterior 

surface of the sacrum and coccyx. The tumors are 
composed of fibrous or granular masses, generally of 
sarcomatous nature ; sometimes of fat, cartilage, or 
bone. Occasionally they involve the spinal canal, or 
surround a spinal, dural protrusion (spina bifida). 
They never extend above the lower border of the 
g ^g^^ gluteus, but spread toward the pelvis and between 

downward. ^|^g l^gg ^f ^he child. 



MALFORMATIONS OF EXTREMITIES. 157 

4. Caudal Formations — 

(a) Complete tails, manifested by an actual increase in 
the number of coccygeal vertebra. 

(b) Imperfect tails, enlargement of vertebral column by 
rudimentary tissue. 

But few children born with coccygeal tumors live beyond the 
age of one year. As the tumors enlarge, the infants succumb 
to progressive cachexia and exhaustion. 

As a rule, sacral tumors do not interfere with the life of the Protection 
child if suitable protection is employed against vulnerability of injury and 
the tumor and secondary infection. In some selected (see Spina 
Bifida) cases perfect results are obtained by skillful surgical 
interference. 



MALFORMATIONS OF THE EXTREMITIES AND HIP. 

Of the numerous malformations of the extremities (e.g., 
complete absence ; spontaneous partial amputations ; fractures ; 
supernumerary fingers and toes, etc.) but few are of interest to 
general practitioners, namely, congenital dislocation of the hip 
and club-foot. As these abnormalities are apt to be confounded 
with similar acquired affections, they will receive special con- 
sideration. 

LUXATIO COX^ CONGENITA 

(Congenital Dislocation of the Hip). 

The dislocation may be unilateral or bilateral. The acetab- 
ulum is rudimentary in form, and the head of the femur rests 
either above it, above and to the outer side, or above and behind 
it upon the ilium, sometimes immediately at the side of the great 
sciatic notch. If one leg is displaced it is shorter than the other, 
giving rise to distinct limping. If both sides are affected the ^"^^.^^^^^ 
gait is wobbling — ''duck gait." As a result of this anomaly the Juttocks^ 
buttocks project prominently backward while the spine is either 
thrown forward (lordosis, in bilateral) or tilted sideways 
(scohosis, in unilateral dislocation). The differential diagnosis 
between this condition and rachitis and coxa vara is best estab- 
lished with the aid of the X-rays which shows the abnormal posi- 
tion of the head of the femur. If the malformation is detected 
early, it may be corrected either by opening the joint, replacement 
and fixation of the head of the femur in the artificially deepened ^pJrluon 
acetabulum or by bloodless forcible reduction of the deformity 



158 



CONGENITAL MALFORMATIONS. 



Differentia- 
tion from 
rachitic 
and para- 
lytic club- 
foot. 



and fixation of the head of the femur in the acetabulum by pro- 
longed use of plaster-of-Paris bandages. For details of treat- 
ment the reader is referred to text-books on "Orthopedic Sur- 
gery." 

TALIPES 

(Club-foot). 

1. Talipes varus, inversion of the foot, so that its sole faces 
the other foot. This is the most common of the congenital forms. 

2. Talipes valgus, flat- 
foot, efTacement of the 
arch. 

3. Talipes equinus, 
lowering of anterior part 
of the foot, the child steps 
on his toes. 

4. Talipes calcaneus, 
elevation of anterior part 
of the foot, heel alone 
touching the ground. 

Compound forms may 
be produced by combina- 
tion of the different varie- 
ties. The diagnosis of the 
type of club-foot can 
readily be made by in- 
spection ; it is sometimes 
difflcult, however, to dif- 
ferentiate the congenital 
from the acquired forms, 
e.g., rachitic or paralytic 
club-foot. In rickets the 
distortion of the feet is 
generally associated with other pathognomonic symptoms 
of rickets and is gradual in development. In paralytic club-foot 
{e.g., poliomyelitis) the Hmb is wasted, flabby and cold and there 
is a history of post-natal, gradual appearance often .in association 
with other paralytic deformities. 

Congenital club-foot is being attributed to various causes, but 
is probably due to some mechanical interference with the normal 
development of the joints, ligaments or tendon insertions. 




Fig. 43. — Congenital Talipes 
Varus. (Sheffield.) 



CHAPTER IV. 
Birth Injuries. 



Nature in its infinite wisdom provides a more or less large 
quantity of liquor amnii to protect the fetus in utero against 
undue pressure and possible injury. If, perchance, the amniotic 
fluid escapes prematurely either spontaneously or artificially, the 
fetus in its descent through the parturient canal, subjected to of pressure, 
powerful pressure by the maternal structures or mechanical 
manipulations, sustains a number of injuries which vary in 
severity from simple external bruising to grave compound frac- 
tures and internal, sometimes fatal, injuries. 

I. SUPERFICIAL STRUCTURES. 
CAPUT SUCCEDANEUM. 

A'ertex presentation being the most common form of delivery, 
the head consequentlv stands the brunt of the injuries. The so- circumscribed 

•^ ' , . . -^ edema. 

called caput succedaneum is a circumscribed edema of the scalp. 
It is observed immediately after birth as a doughy, evenly distrib- 
uted, variously sized tumor which disappears spontaneously by 
absorption, unless infected through external abrasions. In the 
latter event it requires surgical treatment, such as antiseptic drain- 
age, incision and drainage. 

CEPHALHEMATOMA. 

More serious than the aforementioned condition is hemor- 
rhage occurring between the pericranium and cranial bones in 
the form of a circumscribed, elastic, distinctly fluctuating, pain- 
less tumor, situated upon the right or left side of the head (some- 
times both sides are aft'ected). The cephalhematoma develops 
gradually within the first few days of extra-uterine life, and 
owing to the firm attachment of the periosteum to the edges of 
the cranial bones along the sutures, it never extends beyond the 
latter, or over the fontanelles. All around the tumor a hard, 
bony ridge is soon (after about two weeks) detected, wdiich 

(1.59) 



Fluctuating 
tumor. 



Bony 
ridge. 



160 BIRTH INJURIES. 

with the depressed center gives a sensation somewhat like that 
of a depressed fracture. 

Cephalhematoma may be mistaken for caput succedaneum, 

which appears immediately post partum and disappears after a 

'tionfrom day or two; for subaponeurotic or subcutaneous hemorrhages, 

cJdaneu^m' which occur Sometimes also from intrapartum pressure, but 

^ hemorrhage extend bcyoud the sutures; for congenital encephalocele, which 

genital Hcs between but not over the bones, pulsates, enlarges on crying 

encep a oce e. ^^ coughing, and Can be: partially reduced, and, finally, for 

vascular tumors, which are compressible and free from a bony 

ridge. 

The tumor usually disappears spontaneously, sometimes re- 
quiring weeks and months to do it. If suppuration occurs, it 
calls for surgical interference. 

HEMATOMA STERNOCLEIDOMASTOIDEI. 

Pathologically akin to cephalhematoma is the intrapartum 
Hemorrhage hemorrhage which takes place within the sheath of the sterno- 

withm the ^ ^ 

^otthe cleidomastoid muscle, as a result of rupture of several muscle 
muscle, fibers and consecutive myositis. 

The tumor in the neck is generally observed a few weeks 
after birth, more rarely earUer. It varies in size from that of a 
hickory nut to a walnut. It is at first soft, later hard, cartilag- 
inous in consistency. Severe hemorrhages may give rise to 
torticollis. 

This condition demands perfect rest to the head, cold com- 
presses for the relief of pain, and later gentle massage to pro- 
mote absorption of the tumor. 

I^ Ung. kalii iod. (U.S. P.), 

Adipis lanse aa 3ij. | 8. 

M. ft. ung. 

Sig. : To be applied with gentle massage once a day. 

II. DEEP STRUCTURES. 

Birth traumatism is not always limited to the skin and 
muscles. Now and then the viscera (the lungs, liver, perito- 
neum, etc.), the bones, the peripheral nerves, the meninges and 
brain are involved. Fractures and dislocations are not rarely 
observed, especially in the long tubular bones and the clavicle, 
while the cranial bones are often badly displaced (the occipital 
and frontal are pushed under the parietals), fissured (see 



DEEP STRUCTURES. 



161 



^Meningocele"), compressed and fractured, giving rise to grave, 
frequently fatal, intracranial hemorrhages. 

CENTRAL BIRTH PARALYSIS. 

Cerebral Hemorrhage. Apoplexia Neonatorum. 

Usuallv the seat of the hemorrhage is the subarachnoid space-; seat of 

. ' ,. . ^. . , , 1 hemorrhage. 

otten the delicate pia mater ; sometmies between tlie dura and 




Fig. 44. — Obstetric Facial Palsy (.15 months old). Failed to yield 
to treatment. (Sheffield.) 



symptoms 
of cerebral 



arachnoid; more rarely between the meninges of the cerebellum; 
the lateral Axntricles. and exceptionally the brain substance. 

The symptoms differ with the extent and seat of the hemor- 
rhage, ^lost infants are born asphyxiated. The majority of 
those born alive succumb within a few days under symptoms 
of asphyxia and atelectasis, slow irregular pulse, bulging of the p^^^^^'^^^- 
fontanelles. convulsions, rigidity and paralysis. Those few who 
survive, at an early age present the symptom-complex of cerebral 
paralysis (see page 587'). with or without idiocy. 

The diagnosis of this condition in the absence of focal symp- 
toms may present considerable difficulty. Nowadays it is greatly 
facilitated by lumbar puncture, the cerebrospinal lluid containing 
disintegrated blood-cells and products of decomposition. 

11 



162 



BIRTH INJURIES. 



The treatment is the same as for traumatic cerebral hemor- 
Eariy rhage in the adult — principally surgical. Recent results warrant 

operation. , • i • - 

early surgical mtervention. 




Fig. 45. — Bilateral Obstetric Brachial Paralysis, so-called "'Duchenne- 
Erb's Paralysis." (Sheffield.) 



Rarely 
permanent. 



Occasionally 
syphilitic. 



PERIPHERAL BIRTH PARALYSES. 
Facial Paralysis. 
Facial paralysis in the newly born is usually of traumatic 
origin, as a result of pressure exerted upon the facial nerve by 
the obstetrical forceps or deformed pelvis. It may be unilateral 
or bilateral. It resembles facial paralysis of older children (see 
page 541) except that it runs a milder course. Very rarely the 
paralysis is permanent. The so-called congenital, non-traumatic 
facial paralysis is probably syphilitic in nature. 



DEEP STRUCTURES. 



16a 



Brachial Paralysis. Obstetrical Paralysis. 
Duchenne-Erb Paralysis. 

In mild form it is of quite frequent occurrence. In typical 
cases the paralysis is usually limited (80 per cent.) to the 
muscles supplied by the brachial plexus composed of the lower 
four cervical nerves and the first dorsal, and their branches 




Fig. 46. — Bilateral Obstetric Brachial Paralysis (same as Fij 
45), six weeks later. Considerably improved. (Sheffield.) 



i.e., the deltoid, biceps, brachialis anticus, infraspinatus, supinator 
longus and the supinator brevis. 

The arm (rarely both sides [see Fig. 45] are affected — from 
reckless instrumental manipulations) hangs motionless, the 
upper arm is rotated inward, the forearm is pronated, and the 
palm of the hand is turned backward and outward. The wrist- 
and finger-joitits are usually only slightly afifected ; sensibility is 
intact and electrical reaction diminished or lost. 



Usually- 
unilateral. 



164 BIRTH INJURIES. 

Recovery is the rule in mild cases. Those lasting over three 
Trophic rnonths show trophic changes in the affected muscles, especially 
c anges. ^^^^ dcltoid. The prognosis in cases of brachial paralysis present- 
ing reaction of degeneration is doubtful. 

After keeping the affected arm perfectly at rest for two 




Fig. 47. — Obstetric Brachial Paralysis. Erb's "upper arm type." 
Failed to respond to treatment. {Sheffield.) 

Electricity wccks the faradic or galvanic current should then be applied 
massage^ daily, for about five minutes at a time, until muscular power has 
been restored. Gentle massage and passive motion are very 
useful as a prophylactic against atrophy and contractures. In 
complete rupture of one or more cords of the brachial plexus, 
nerve end to end anastomosis and tendon transplantation are 
the only curative means at our command. 



CHAPTER V. 
Diseases of the Newly Born. 



FEEBLE VITALITY OF THE NEWLY BORN. 

The physician is often confronted by a group of clinical 
phenomena in the newly born which may briefly be designated 
"feeble vitality." It is a clinical entity which, though greatly at 
variance as to cause and ultimate course, at birth presents a uni- 
form symptom-complex and demands a more or less uniform 
mode of treatment. 

It is characterized by pronounced respiratory and circulatory 
disturbances, subnormal temperature, somnolence, general debility 
and emaciation, and is usually associated with one or several 
presently to be described diseased conditions. 

1. ASPHYXIA NEONATORUM 
(Suspended Animation). 

The asphyxia may be momentary, or last several minutes up 
to an hour or lons^er. Mild forms of asphyxia are manifested 

-^ Asphyxia 

by slight lividity (asphyxia Hvida) of the face, feeble superficial iivida. 
breathing, and slow and weak heart-beat. If the asphyxia is 
allowed to continue, the face becomes deeply cyanosed and con- 
gested, the eyes bulge, the muscular tonus and cutaneous sensi- 
bility are retarded, the umbilical cord is collapsed, and respira- 
tion is barely perceptible. Finally, the infant becomes deathly 
pale (asphyxia pallida), the muscular tonus and reflexes are lost, ^^fj^g^^^ 
the heart-beat is scarcely audible and respiration ceases. 

Post-mortem examination reveals overdistention of the right 
ventricle ; cerebral, pulmonary and hepatic congestion ; increased 
fluidity of the blood; serosanguinolent exudation in the serous 
cavities ; accumulation of liquor amnii, blood and mucus in the 
air passages, and pulmonary atelectasis. 

Prompt and prolonged resuscitating eflforts (Sylvester's, Artificial 
Schultze's and Laborde's) are usually attended by favorable respiration, 
results. However, intracranial hemorrhage with consecutive 
mental and physical defects are not infrequent sequelae of severe 
forms of asphyxia. 

(165) 



166 DISEASES OF THE NEWLY BORN. 

2. ATELECTASIS NEONATORUM 
(Congemtal Collapse of the Lungs). 

Inflation of the lungs of the normal ne;wly born infant begins 
with its first cry uttered announcing its arrival into the domain 
inflation of the living. Succeeding respiratory acts gradually unfold the 
lungs, originally collapsed alveoli and bronchioles, and full expansion 
of the lungs is ordinarily completed within the first forty-eight 
hours. The posterior portions of the lower lobes, particularly 
the right, are last to expand. 

Failure of the lungs fully to unfold gives rise to. the condition 
under discussion, ?.^.; atelectasis pulmonum. 

The alveoli and 'bronchioles are collapsed. The lung "is 
brownish red in color, feels tough and resistant to the touch 

Pathologic ,., ,. ■ ; ° . , 

findings. —like livcr — does not crepitate, and sinks m water. Usually 
both lungs, particularly the posterior parts of the lower lobes, 
are afifected. Irl cases sticcumbing to the disease after weeks 
or months there is also congestion of the heart, spleen and 
liver. 

The causes of atelectasis are essentially the same as those of 

asphyxia; the former is sometimes a sequel of the latter, espe- 

„ cially if inadequately treated. Inflation of the luns^s is occa- 

Occasionally . ., . . . 

caused by sionallv interfered with by cons^enital hyperplasia of the thyroid 

compression -^ j g ./ rr t- j 

of trachea, or thymus glands compressing the trachea. 

In marked atelectasis the infant makes but faint efforts to 
respire. It is pale, sometimes cyanotic; its temperature is sub- 
normal, and its pulse slow and weak. It is unable to suckle 
properly and to cry aloud. It sleeps most of the time and but 

respiration; lazily responds to external influences. Auscultation discloses 

cyanosis. -^^. , .... ., 

weak and vesicular breathing (never bronchial) and occasional 
crepitation. Slight dullness on percussion. 

The great majority of otherwise healthy children recover 
under prompt and energetic treatment. Delicate infants either 
die a few hours, days or several weeks after birth from prostra- 
tion following repeated attacks of cyanosis, or survive and 
remain debile for life, often suffering from organic defects, 
such as incomplete closure of the foramen ovale or ductus arteri- 
osus, and the like. 

The treatment of atelectasis' consists in stimulating the 

Artificial respiratoty and circulatory functions by keeping the infant wide 

sitlSStion! awake; frequent change of position; artificial respiration; alter- 



FEEBLE VITALITY. 167 

nating warm and cold baths or showers followed by brisk fric- 
tion; oxygen inhalation and gentle fax'adization. Lustily crying 
babies do well. 

3. VITIA CORDIS. 

' ( See page 428. )/ 

4. SYPHILIS EMBRYONALIS S. FCETALIS. 

The few babies who survive the syphilitic onslaught during 
intra-uterine life and are born at full term present a ghastly sight. 
They are shriveled and shrunken, emaciated and disfigured, with shriveled 
barely a spark of life in them. They are often asphyxiated and shrunken^ 
usually die soon after birth. Post-mortem examination reveals 
pronounced pathologic changes in the lungs (fatty degeneration 
of the pulmonary alveoli— "pneumonia alba") ; in the liver (in- Post- 
terstitial hepatitis) ; in the spleen and pancreas (induration and findings, 
gummatous deposit) ; in the kidney's and suprarenal glands (peri- 
vascular infiltration and anemic necrosis); in the thymus gland 
(cystic degeneration and abscess formation) ; and in the osseous 
system (epiphyseal osteochondritis after multiple fractures). 
The skin affection consists chiefly of "pemphigus syphiliticus," Pemphigus. 
a bullous eruption on a dusky red, slightly elevated base, with a 
sanguinopurulent content. It is usually localized on the palms 
of the hands and soles of the feet. Owing to extreme tenderness 
of the body (syphilitic myositis?) the infant is very restless, and 
cries pitifully when handled. (See Syphilis Congenita.) 

5. PREMATURE BIRTH. 

Children born before full term — between the twenty-eighth 
and thirty-eighth weeks of intra-uterine life — are designated 
"premature." 

Thanks to the earlier and better recognition of syphilis, the 
more thorough appreciation of the methods of its prevention and 
cure, as well as the tendency of the syphilitic virus spontaneously 
to lose its virulence through attenuation^ premature births, being 
due chiefly to parental syphihs, are no longer as frequent in 
occurrence as in former years. 

The physical condition of premature infants rests largely upon 
the period of prematurity, inherent vigor of the newly born, and 
the presence or absence of serious organic defects. Ordinarily 
premature infants are considerably punier than full term infants. 
They weigh and measure approximately:^ „ - ;, ', 



Often 
caused by- 
syphilis. 



168 DISEASES OF THE NEWLY BORN. 

Age at Birth. Weight. Size. 

At 29 weeks 1600 Gm.— 3^ tb. 40 Cm.— 15 inches. 

" " ' ""' 4 " 43 " 16^4 



31 
35 
40 



1900 
.2100 
,2600 
.2800 



^V^ " 44 " 16/2 

5^ " 47 " 1734 

534 " 48 " 18 

(full term) ..3100 " 64 " 52 " 19>^ 



The body is limp; the movements of the extremities are help- 
less and tardy. The face is usually sunken and senile. The skin 
is soft and delicate, vulnerable to an extreme, hence readily sus- 
ceptible to infectious processes. Respiration is irregular, super- 
Extremeiy ^^^^^ ^^^ sometimes of Chcync-Stokes type. Atelectasis and 
vitaiit^ cyanosis are not rare accompaniments. The heart beat and pulse 
are weak, often irregular, and the blood lacks in coagulating 
power. The bones are soft, more or less yielding to light manip- 
ulation. The temperature is subnormal. Premature infants, as 
a rule, are unable to suckle or swallow properly, and owing to 
incapacity of the digestive organs and atony of the intestinal 
musculature, to fully assimilate the food consumed. Severe 
. colic and uric acid infarcts, which latter often lead to anuria and 
other uremic manifestation, add misery to their painful existence. 
Encumbered with so numerous deficiencies, the span of life 
of the delicate premature infant must obviously measure but a 
moTtSlty. ^^w hours or days. The mortality of premature infants under 
1600 grammes in weight, especially if they are inadequately cared 
for, is estimated to be about 80 per cent. ; of those weighing over 
2000 grammes, 40 per cent. ; while of those weighing over 2500 
grammes only 20 per cent. — almost as low as with full-term babies. 
Such as survive, however, often remain very feeble for many 
years, manifest a greater tendency to disease, and lack power of 
resistance to overcome it. Occasionally, after many ups and 
Recovery downs, premature infants marvelously extricate themselves from 
suitable the pangs of death and grow up full of vivacity and vigor, 
treatment. j^. -g therefore incumbent upon the physician to look upon 
every premature infant that respires at birth as one whose life 
can be preserved by suitable care and treatment. 

Management of "Feeble Vitality of the Newly Born" with 
Especial Reference to the Premature Baby. 

Three special indications are to be met in the management of 
newly born, delicate infants. We must (1) endeavor to maintain 
the best features of antenatal life; (2) supply nutriment suitable 



FEEBLE VITALITY. 



169 



for the infant's growth and development and (3) awaken and 
strengthen the dormant or inefficient functions of its organs. 

The first prerequisite should be met by an artificial environ- Artificial 
ment which should as nearly as possible resemble that of the ^^^^^' 




jlliiiiiiBijinjujiiiiiiiiiiiiiini* 

lli!iilhliiil,Pil'Hllli««IIIH" 

oiliUllniyiiiiiiwiuDMiiiuuH 
iilllliiyiiWiii»iJiii«iiii*iii 
]lliiiliiiil;;liiiiiiu«iuiiii«ittii 




Incubator for Premature Infants. 



interior of the uterus. The numerous modern incubators on the 
market in many instances answer the purpose. The infant is 
clothed in a woolen shirt and napkin and placed in the incubator, 
upon a cotton bed. 



Incubator. 



170 



DISEASES OF THE NEWLY BORN, 



Careful 
feeding. 



The temperature of the incubator is maintained steadily at 
about 96° F., and fresh air suppHed by the automatic ventilating 
contrivance and by off and on leaving the door open. Infants 
showing: a fair amount of vitality usually get along very well 
without incubators, the latter being supplanted by ordinary 
bassenets and warm-water bags. Delicate incubator babies should 
be disturbed as little as possible, and removed only for feeding 
and cleansing (by means of lukewarm oil), or for such thera- 
peutic purposes {e.g., artificial respiration) as necessity arises. 




Fig. 49-. — Incubator Room for \ eAA Iv Born Babies with Feeble 
Vitality. Prof. Th. Escherich. (Sheffield.) 

Bathing is contraindicated, and any undue handling of the skin or 
mucous membranes must be carefully avoided, since most trifling 
injuries are very apt to be followed by fatal sepsis. 

Every effort should be made to feed the premature infant on 
woman's milk, for at least the first few weeks of extra-uterine 
life. When too weak to suckle from the breast, the milk may be 
given in diluted form (1:2) by means of a dropper or little 
spoon, care being taken that the milk flows down into the throat 
very slowly, lest it enter the trachea and lead to aspiration pneu- 
monia. In the absence of breast milk, light mixtures of cows' 
milk (^ per cent, of fat, >4 per cent, proteids and 5 per cent, of 
milk-sugar) should be administered every hour or two, in quan- 
tities of 1 to 4 teaspoonfuls. 



FEEBLE VITALITY. 171 

The third indication appHes principally to infants who, though 
born at full term, possess very little vitality, and whose organs, 
especially the heart and lungs, fail to functionate. This vitality stimulation, 
is best aroused by artificial respiration— by alternate flexion and 
extension of the infant's body while it lies on the operator's 
palms. An occasional dash of cold water upon its face, to induce 
the child to cry aloud and take deep breaths, and stimulation by 
means of oxygen and strychnine, serve as useful adjuvants. 

SCLEREMA NEONATORUM 
(Sclerema Adiposum). 

This very rare affection may be primary, without any appar- 
ent cause, or secondary in nature, as a result of great loss of ,^ 
body fluids (internal hemorrhages, gastrointestinal .disease), or 
extensive exudations into internal cavities (thorax). It occurs 
principally in the premature, very feeble and badly nourished 
infants in the first few days of Hfe (but also very much later, 
up to six months of age). 

It begins in the lower extremities, particularly the calves. Begins 
From here it spreads symmetrically over the thighs, loins, trunk, extremities. 
neck, upper extremities and head, leaving penis, scrotum, planta 
pedis and palma manus uninvolved. The skin is dirty yellow, 
very tense, cold, hard, immovable over the underlying struc- 
tures, and does not pit on pressure. 

From day to day the skin becomes more indurated, marble- Marbieized. 
ized, and the patient lies stifif with rigid, mask-hke face and 
firmly closed mouth as though in a state of tetanus. Suckling is interference 
often impossible. There is gradual sinking of all vital func- guckiing. , 
tions. The temperature falls (to 85° F. or lower), the heart 
action becomes w^eak, the pulse is slow and barely perceptible, subnormal 
respiration shallow and irregular, the voice feeble and whining, ^°^p®^^ "^®- 
the intestines and kidneys are inactive, the child wastes rapidly, 
and death ensues in about a week from exhaustion or some 
complication, the commonest being pneumonia and sepsis. 
Milder cases, especially older infants, not infrequently recover. 

Early hypodermo- and entero-clysis with hot (104° to 106° Active 
F.) normal saline solution (from 2 to 3 ounces t. i. d.) ; gentle 
massage with oil ; stimulation ; maintenance of body heat ; careful 
feeding, etc., as outlined under 'Teeble Vitality of the Newly 
Born." (See page 168.) 



172 



DISEASES OF THE NEWLY BORN. 



SCLEREDEMA NEONATORUM 
(Sclerema Serosum). 

This form of edema affects especially premature, weak 
(twins), atelectatic, and syphilitic infants. It usually begins a 
few days post partum (it is rarely congenital) with puffiness and 
swelling of the feet and legs. The edema soon extends upward 
(involving also the mons veneris, scrotum and penis) over the 
usuaify entire body, except the chest, and rarely the eyelids and face. 
free, -pj^^ ^j^-^ -^ ^^j^gg^ shiny, waxy white, or cyanotic, and pits on 
pressure. When the edema increases it greatly resembles true 
sclerema, but may be differentiated from the latter by bearing in 
mind the following characteristic symptoms : — 



Differentia- 
tion from 
sclerema. 



Sclerema. 

Color of skin Dirty yellow. 

Parts exempt Genitals, palms of the 

hands and soles of the 

feet. 
Pitting on pressure Absent. 



Scleredema. 
Shiny or mottled, 
Chest. 



Marked. 



The general symptoms, such as low temperature, great de- 
pression, etc., are not quite as pronounced as in sclerema 
adiposum. 

The prognosis is not as grave as in true sclerema. 

The treatment consists chiefly of stimulation (camphor, 
stimu_iation; digitalis), hot baths, massage and passive motion, active diuresis 
and proper feeding. See also "Feeble Vitality of the Newly 
Born." 

SEPSIS NEONATORUM. 

With the usual aseptic precautions that are now being taken 
in the management of labor and the puerperium, the number of 
cases of sepsis neonatorum has been reduced to a minimum. 
This is true especially of systemic sepsis. The extreme impor- 
tance, however, of the subject in question, demands its careful 
consideration. 

LOCAL SEPSIS. 

Omphalitis (Inflammation of the Navel). 

Simple omphaHtis is manifested by delayed closure of the 

umbilical wound after separation of the umbilical cord, wetness, 

inflammat°o5^ slight suppuration, and incrustation. There is no inflammatory 

reaction in the surrounding parts. The general health is 

undisturbed. 



SEPSIS NEONATORUM. 173 

Phlegmonous omphalitis usually begins the second week after 
birth. The navel forms an ulcerated conical projection. The conical 
surrounding tissue is firm, infiltrated, glossy and painful to the ^^"■'^^ ^'^^' 
touch. Sometimes the inflammation extends rapidly over the 
abdominal wall or into the deeper structures, giving rise to peri- 
tonitis. The constitutional symptoms vary with the degree of Constitutional 
severity of the affection, but are sufficiently pronounced as to 
make the child quite ill and to render the prognosis doubtful. 
Milder cases often terminate in suppuration and with careful 
treatment (see page 174) in recovery. 

Erysipelatoid omphalitis is a very grave affection, often ter- 
minating fatally either within a few days from exhaustion or a 
week to ten days later from septic peritonitis, icterus, and local septic 

symptoms. 

suppuration. The symptoms and treatment are the same as in 
ordinary erysipelas. 

Diphtheritic omphalitis (ulcus umbilici) is characterized by 
a fibrinous umbilical exudation which when cast off leaves behind Kiebs- 

Loffler 

a superficial or deep ulcer. Occasionally it is due to Klebs- baciiii. 
Loffler bacillus. 

Gangrenous omphalitis ends fatally in the majority of cases. 
At first a small, discolored, ulcerated spot, if not immediately sloughing. 
arrested, it rapidly develops into a large, gangrenous, fetid mass. 
It sometimes extends into the deeper structures, giving rise to 
peritonitis, urinary and fecal fistulas, profuse hemorrhage and 
pronounced constitutional symptoms. 

As the umbilical wound forms the principal and most fre- 
quent portal of entry for septic infection, the importance of 
caring for the umbilicus with the minutest detail is quite obvious. 
Strictest cleanliness should be enforced and unnecessary hand- Aseptic 

. 1 ,. ^11 precautions. 

Img prohibited. Clean scissors, clean ligature, preferably com- 
posed of several strands of cotton or silk thread, and, above all, 
clean hands should be used in cutting, ligating, and dressing the 
cord. The dressing should consist of a few layers of sterile Dry 
linen cloths and a dusting powder (1 part of salicylic acid and ofnavei. 
6 parts of starch) and be changed every alternate day, preceded 
by cleansing the wound with a little pure alcohol to hasten desic- 
cation of the umbilical rest. As moisture favors the growth and 
absorption of the bacteria which accumulate at the navel wound, 
the child should daily receive a sponge-bath instead of a tub- 
bath, until the navel has completely cicatrized. 

To prevent hernia as well as access of dirt, the umbilical 



Diphtheria 
antitoxin. 



174 DISEASES OF THE NEWLY BORN. 

band should be continued for some time after complete healing 
of the navel. 

If inflammation of the navel, no matter how slight in degree, 
energetic occurs notwithstanding all the precautions, it should receive 
rea men . [^^^q(^[^^q ^^^ cnergctic treatment. Procrastination is danger- 
ous, nay, often fatal. 

Cauterization of the affected parts with a 2 per cent, to 5 
per cent, solution of nitrate of silver, once a day or less often, 
^ silver, is vcry useful in all forms of omphalitis. The wound should be 
kept scrupulously clean, and protected by a moist (boric acid 
solution 4 per cent.) gauze dressing, covered by rubber tissue. 
If the septic process does not yield to this treatment early, a 
surgeon should be consulted. A bacteriologic examination may 
prove helpful in giving a correct clue as to the treatment, as for 
example, in diphtheritic omphalitis, where diphtheria antitoxin 
is of undoubted benefit. (See also ''Biologic Therapeutics," page 
94.) 

Omphalorrhagia (Bleeding from the Navel. Idiopathic 
Umbilical Hemorrhage). 

Umbilical hemorrhage may occur as a result of tearing of 
the cord during delivery, defective ligation, or imperfect estab- 
lishment of respiration (delaying the closure of the umbiHcal 
vessels). The hemorrhage may be slight or severe, but is readily 
controllable. In contradistinction to these forms of navel bleed- 
ing which take place soon after birth, there is another variety 
of bleeding from the navel, the so-called ''Idiopathic or Spon- 
taneous Umbilical Hemorrhage" which occurs at about the time 
the umbilical rest separates (between the fourth and ninth days). 
The bleeding takes the form of a steady oozing of blood as 
though coming from a compressed wet sponge. It is probably 
"°^^iiicai ^yg ^Q sepsis of the umbilical blood-vessels. Some authors are 
vessels, inclined to attribute it to congenital syphilis or transitory hemo- 
phiHa (see page 477). In a great many instances the hemor- 
Hemophiiia. rhage Cannot be arrested, death taking place either from exsan- 
guination or from gradual exhaustion and comphcations (sepsis). 
For details of treatment see "Hemorrhea Neonatorum" 
(page 181). 

Umbilical Granuloma (Excrescence, Fungus, Sarcomphalos). 

strawberry- It is a strawberry-likc, small tumor, attached to a broad 

tumor^ base or pedicle at the umbiHcal stump. It bleeds readily and 



Sepsis of 



SEPSIS NEONATORUM. 175 

usually discharges thin pus. Like exuberant granulations in 
■other localities, it is promptly cured by a few applications of 
nitrate of silver (the stick or 10 per cent, solution). It should 
not be confounded with "Persistent Omphalomesentericus." 
{See page 146.) 

Ophthalmoblennorrhea Neonatorum (Gonorrheal or 
Purulent Ophthalmia). 

Gonorrheal ophthalmia is caused by infection of the con- 
junctiva of one or both eyes by the gonococcus (Neisser). The 



Nitrate 
of silver. 




Fig. 50. — Gonococcus. (Gonorrheal Pus.) Stained one- 
half minute with methylene-blue. a, Free in groups. b, 
Enclosed in pus cells. Leitz ocular I. Oil immersion I/I2. 
(Lenharts and Brooks.) 

inoculation usually occurs during the passage of the head through 

the parturient canal containing a gonorrheal discharge. It may Gonorrheal 

also be conveyed to the eyes of the infant post partum by means 

'Of the fingers of the attendant or articles in use which have been 

soiled by the purulent discharge. 

The disease begins two or three days after the gonorrheal 
inoculation w^ith intense tumefaction of the lids, redness, swell- 
ing and thickening of the conjunctivae, lacrimation, and mucous 
and mucopurulent secretion. From day to day the discharge Thick, 
iDCcomes thicker and more purulent; the conjunctiva assumes a discharge, 
velvet-like appearance (chemosis), and papillary deposits or 
longitudinal folds appear upon the conjunctiva bulbi. If not 
immediately arrested, especially if the purulent secretion is 



176 DISEASES OF THE NEWLY BORN. 

allowed to accumulate between the edematous, pasted lids, the 
disease spreads rapidly to the cornea, causing haziness, macera- 
invoivement tion and partial or total perforation. As a result of the latter 
and depending upon its location total or partial staphyloma, 
panophthalmitis with phthisis bulbi, capsular cataract, and 
anterior synechise may supervene. 

Occasionally, particularly in delicate infants, gonorrheal con- 
junctivitis gives rise to numerous complications, such as articular 
aifections, gonorrheal rhinitis, stomatitis, etc. 

The duration of the disease varies from four to eight weeks. 

Until the introduction of Crede's method of prophylaxis, 
gonorrheal ophthalmia was supposed to have contributed 60 per 
cent, of the cases of blindness of one or both eyes. At present 
tne percentage has been reduced to one-third and with early and 
careful treatment the prognosis is still more favorable. 

Gonorrheal ophthalmia is not to be confounded with the 
simple conjunctivitis not infrequently met in the newly born in 
connection with local sepsis. The latter variety is readily 
recognized by the absence of gonococci in the discharge and by 
its much milder course. Where there is the least suspicion of 
gonorrhea in the mother, her parturient canal and external geni- 
talia should be carefully disinfected by a bichlorid solution (1 to 
5000) before, during and after delivery. In addition to this the 
method^ following directions given by Crede in the way of prophylaxis 
should promptly be resorted to : Wash off each eye w4th a boric 
acid wipe ; into each eye instill two drops of a 2 per cent, solution 
of silver nitrate ; in about thirty seconds wash out the excess 
with saline solution. This should be done as early after birth as 
possible. During the puerperal state the child should be kept 
away from the mother. In absence of gonorrhea, the infant's 
eyes should be washed with a saturated solution of boric acid. 

If only one eye be infected the fellow-eye should be securely 
of*heaithJ covcred by a watch-glass or a small pad of lint, oiled silk and 
^^^- roller bandage. This protected eye should be inspected and 
cleansed twice daily. 

As soon as the child is seen by the physician he should pencil 
Nitrate ^hc affected eye with a 2 per cent, silver solution. If this occurs 
of silver, g^j-ly, the Ophthalmia may sometimes be arrested in its incipiency 
or at least rendered milder in its course. 

The affected eye must be handled by the nurse from behind 
the patient's head. Small, round layers of lint are transferred 



Ice cloths. 



SEPSIS NEONATORUM. . 177 

every three to five minutes from a large square of ice to the 
affected eye, continuously for one hour. An intermission of one 
hour is then given and the cold applications are resumed. This 
should be continued day and night until there is positive evidence 
of abatement of the inflammation and excretion. This usually 
occurs within two weeks. The eyes should be carefully but very 
gently cleansed every half an hour with warm saturated solution cilanfmg. 
of boric acid (4 per cent.). If the lids are so swollen as not to 
permit thorough cleansing, canthotomy may be resorted to. 
Silver being the most proficient antigonococcus, a 2 to 3 per 
cent, solution should be applied to the conjunctiva daily as long 
as the excretion is profuse and less often when it becomes more 
scanty and less purulent. In involvement of the cornea the ice- 
cloths should be discontinued, but not the silver applications. A 
I per cent, solution of atropine should be used as necessity 
arises. 

Examination of the discharge for gonococci should be made 
at least once a week, and the case should not be regarded non- 
contagious and out of danger until the discharge from the eye Repeated 

. 1 ^T^i examination 

remams free from gonococci for at least two weeks. The treat- of discharge 

for gono- 

ment of gonorrheal ophthalmia should not be intrusted to 
unskillful hands. The better trained the nurse is in handling 
serious eye cases, the more rapid and perfect the recovery. 



Pemphigus Neonatorum. 

Simple, non-syphilitic (see page, 400) pemphigus makes its 
appearance between the fifth and twentieth day of the child's 
life. It is quite communicable, sometimes epidemic, and is communi- 

^ ^ cable. 

probably due to the staphylococcus pyogenes aureus. Its seats 

of predilection are the abdomen and inguinal region, but the 

lesion may be found on any part of the body. It but very ^^^™^ ^^^ 

rarely affects the palms of the hands and soles of the feet — soies of feet 

. . . ... . usually 

herein markedly differing from syphilitic pemphigus. The erup- free. 
tion consists of tense bullae, varying in size from a lentil to a 
quarter of a dollar piece and contains a serous, rarely seropuru- 
lent fluid. The blebs are situated upon a reddened base, and on 
bursting leave moist red spots which very soon are covered over 
by skin. Occasionally ulceration of the skin supervenes, and is 
accompanied by high fever and other constitutional symptoms 
(malignant pemphigus). This severe form of the disease is pemphigus. 

12 



COCCI. 



17 



DISEASES OF THE NEWLY BORN. 



observed particularly in cachectic and bottle-fed infants, exposed 
to unsanitary surroundings, and often leads to fatal issue. In 
otherwise healthy, well-nourished and well-kept infants, recovery 
may be expected within from two to three weeks. 

Simple pemphigus is preventable by strict attention to general 
hygiene and proper feeding. Those in charge of the child should 
Isolation, be cautioucd as to the communicability of the disease. If large 
surfaces are involved warm baths are very useful, preferably 
with oak bark (quercus corticis), bran or clay. They may be 
administered two or three times a day and followed by dusting 
over the moist surface 

B^ Bismuthi subgall., 

Acidi salicyl aa gr. x | 0.6 

Zinci stearat Bj | 30. 

and enveloping the body in cotton. Occasionally, application 
of a 2 per cent, solution of nitrate of silver. 



Dermatitis Exfoliativa Neonatorum. 

Slight dermatitis, or erythema, with or without desquamation, 
is more or less physiologic in the newly born. There is, however, 
an obscure (sepsis?) form of exfohative dermatitis which is 
peculiar to early infancy (usually in the second, rarely after the 
fifth week of life), and is closely related to pemphigus. It begins 
Rhagades. with inflammation of the oral mucous membrane, rhagades at 
the angles of the mouth and diffuse redness of the entire body. 
Large followed by active desquamation of the skin in large lamellae. 
It is sometimes preceded by detachment of skin and bursting of 
vesicles filled with clear fluid. Not infrequently the erosions 
extend to the oral mucous membrane. 

The disease runs its (afebrile) course in a few weeks, and in 
Bad prog- robust children ends favorably. In delicate children it may be 

nosis m -' -^ _ 

cMid?en^ followcd by general furunculosis or even gangrene, gastroin- 
testinal disturbance and pneumonia and prove fatal. 

Like non-syphilitic pemphigus, dermatitis exfoliativa is pre- 
ventable by scrupulous cleanliness, and avoidance of local irrita- 
tion. The local treatment consists of inunctions of 1 per cent, 
salicylic or carbolic acid oil. 

GENERAL SEPSIS. 

In speaking of primarily local septic affections attention has 
been directed to the frequency with which grave constitutional 



SEPSIS NEONATORUM. 179 

symptoms are observed during their protracted course. In these 

cases the systemic manifestations are secondary to the local 

ones, and if the latter are detected and treated early, the former prophylaxis. 

may be prevented or arrested in their incipiency. We are now 

about to describe a group of septic diseases in the newly born 

which either present no visible local lesions at all, or so slight 

as to escape attention in their early stages. 

Tetanus (Trismus) Neonatorum. 

Tetanus in the newly born, like the corresponding disease in 
the adult, is due to the tetanus bacillus (Nicolaier, Kitasato). 






/ 




Fig. 51.— Bacillus Tetani. X lUUU. (After Frdnkel and Pfeiffer.) 

Infection usually occurs through the umbilical stump or circum- j^fg^tion 
cision wound. The bacillus multiplies by spore-formation and through 

^ -^ ^ open wound. 

generates toxins which enter the system, and are absorbed prin- 
cipally by the endings of the motor nerves. From here the 
toxins are ultimately carried to the anterior horns of the spinal 
cord and the nuclei of the medulla oblongata — hence the tetanic 
contractions. 

The symptoms begin within the first week after birth, rarely 
later (after ritual circumcision), with restlessness, dropping of ^'°^'^^'^^- 
the nipple of the breast or bottle with a cry, and tension of the 
masseters. The spasm rapidly involves the orbicularis oris and 
palpebrarum muscles, the lower jaw becomes rigid, the mouth 



180 



DISEASES OF THE NEWLY BORN. 



proboscidiform, the forehead and cheeks are wrinkled, and the 

eyehds are half closed (risus sardonicus). The hands are 

Spasmodic clcnchcd, the legs flexed and abducted and, varying with the 

:ontraction ■, r •. r ,i ,, i i • i , , 

)fextremi- degree ot seventy ot the attack, there is more or less marked 
isthotonos! opisthotonos. At first the paroxysms occur only during the act 
of nursing, gradually, however, more frequently and more per- 
sistently. In severe cases there are also spasmus of the glottis, 
of the esophagus, and diaphragm, and in consequence attacks of 
asphyxia which may end fatally. On the other hand, the affec- 
tion may run a protracted course, sometimes for weeks, and 
end occasionally in recovery. 

The more violent the attacks and the higher the tempera- 
ture, the less favorable the prognosis ; 70 per cent, of the cases 
succumb within a few days, either from spasm of the diaphragm 
or, more rarely, from exhaustion. 
Asepsis. Careful protection against wound infection and prompt atten- 

tion to existing traumatism. Considering the very grave prog- 
nosis under the ordinary methods of treatment and the occa- 
sional success obtained by means of hypodermic or subdural 
Tetanus administration of tetanus antitoxin, the latter should be resorted 

antitoxin. ,, , . . , , , . . 

to at the earliest possible time, either as a prophylactic imme- 
diately after the injury (1500 units) or as a curative measure 
(3000 units p. r. n.), in addition to the symptomatic treatment 
generally in vogue. This consists of perfect rest, lukewarm 
baths, chloral hydrate and the bromides per rectum, feeding 
(mother's or diluted cows' milk) with a tube through the nose, 
and avoidance of any irritation of the skin. 



Arteritis and Phlebitis Umbilicalis. 



Usually 
secondary 
to ompha- 
litis. 



Intense 
icterus. 



This condition is usually observed secondarily to omphalitis, 
but may occur as a primary disease. In the latter event no local 
alterations are discernible at the navel and the grave affection 
frequently escapes notice until pronounced symptoms of general 
sepsis make their appearance. These consist of restlessness, 
fever, prostration and death within a few days, or gradual 
exhaustion from numerous complications. In umbilical phlebitis 
intense icterus — from extension of the inflammation to the liver 
— forms a characteristic symptom. In some cases of arteritis and 
phlebitis umbilicalis a fistulous tract is observed at the navel 
which on pressure discharges blood and pus 
genie micro-organisms. 



containing patho- 



Antistrepto- 
coccic 
serum. 



Rapidly 



SEPSIS XEOXATORUM. ISl 

For prophylactic and local treatment see "Omphalitis" (page 
172). The constitutional symptoms call for symptomatic treat- 
ment. Thus, careful feeding, preferably breast milk; active 
stimulation by means of enteroclysis, hypodermoclysis, sterile 
camphorated oil, etc. Antistreptococcic serum is deserving of 
trial. 

Erysipelas Neonatorum. 

This affection begins suddenly, with high fever, convulsions, 
and often other symptoms of general sepsis. The glossy redness 
rapidly extends over large areas, often over the entire body. The |?ol?y^"^ 
disease proves fatal in a few days and the cases that survive the ^^'^^e^^- 
acute attack usually succumb to cutaneous necrosis (particularly 
of the scrotum, extremities), copious diarrhea, septic peritonitis, 
pneumonia and exhaustion. 

The treatment is principally prophylactic. The inflamed 
areas should once a day be painted with pure ichthyol. 

HEMORRHEA NEONATORUM ACQUISITA. 

Helena Vera. Epidemic Hemoglobinuria with Icterus 

(Winckel's Disease). Acute Fatty Degeneration 

(Buhl's Disease). 

Latest investigations tend to establish the fact that the afore- 
mentioned symptom-complexes in all probability are part-mani- 
festations of general sepsis of the newly born. ^Mention, how- ^^p^^^- 
ever, may be made that congenital heart disease, syphilis, and 
"feeble vitality'' serve as predisposing causes. 

1. Helena Neonatorum. 

Helena vera should not be mistaken for melena spuria, in 
which condition the blood originates from erosions in the mouth 
or nasopharynx, or from swallowing of blood from fissured 
nipples, etc. 

Melena vera usually begins in the first few days of the child's 
life with bleeding from the bowels, and often with hematemesis. 
As a rule, the blood is mixed with stool, and is dark brown or ai^j^enSiT 
black in color. In some cases the loss of blood is slight, recurs at ^^^^i- 
long intervals and terminates spontaneously without serious con- 
sequences except tedious convalescence. In the majority of 
cases of genuine melena, however, the bloody discharge is pro- 
fuse and leads to rapidly increasing anemia and collapse. 



Symptoms 
of general 



True and 
false. 



182 DISEASES OF THE NEWLY BORN. 

2. Epidemic Hemoglobinuria with Icterus in the Newborn 
(Cyanosis Icterica cum Hemoglobinuria, Winckel's Disease). 

This extremely grave (90 per cent, mortality) epidemic affec- 
tion makes its appearance about the fourth day post partum, in 
apparently healthy-born and well-developed children. The 
infant becomes restless, refuses nourishment, shows signs of 
respiratory disturbance and shght rise of temperature. The 
skin turns greenish-yellow, and soon deeply jaundiced and cyano- 
tic. Collapse, somnolence and convulsions, rarely preceded also 
Hemoglobin, j^y vomiting and diarrhea (no blood), are rapidly followed by 
cens?n ^^^th. The urine is pale brown, contains hemoglobin, renal 
urine. epithcHum, granular and blood casts, and masses of detritus, but 
no free blood-corpuscles. 

The autopsy reveals congestion and fatty degeneration of the 

Patiioiogic ii^ternal organs, with punctiform hemorrhages, especially in the 

findings, niucous and serous membranes ; masses of granular hemoglobin 

in the kidneys and spleen, thickening of the blood, and slightly 

increased leucocytosis. 

3. Acute Fatty Degeneration of the Newborn (Buhl's Disease). 

The essential anatomical features of this rare but very 
Fatty malignant affection are fatty degeneration of the internal organs, 
of internal notably the heart, liver and kidneys, and hemorrhages in any 
of the viscera, and into the serous cavities. 

The disease attacks full-term infants who for some inexpli- 
cable reason are born asphyxiated. Those few who survive, 
. , . respire badly, are cyanotic, or rather icteric, and present hemor- 
Hemorrhages, rhagcs in the skiu and mucous membranes, from the ahmentary 
canal, and the umbilicus. They almost invariably succumb 
before the end of the second week from progressive anemia, 
anasarca, and collapse. 

Treatment. — The indications for the treatment of any of 
the manifestations grouped under "Hemorrhea Neonatorum 
Acquisita" are: 1, to arrest the hemorrhage; 2, to improve or, 
at least, maintain the vitality of the newly born infant. The 
first indication may be met by the administration of sterile ( !) 
Gelatin Warm gelatin subcutaneously ( 10 per cent, solution, in doses of a 
quarter to half an ounce three times a day), per rectum (one to 
two ounces) and by mouth (2 per cent, to 5 per cent, solution, 
a teaspoonful t. i. d.), in addition to local hemostasis by means 



FLWCTIOXAL DISORDERS. 183 

of adrenal solutions, perchlorid of iron, packing, compression, 
and cauterization (by nitric acid, Paquelin cautery). \evy 
recently good results have been reported from hypodermatic in- Fresh 
jection (once or twice) of 5 cubic centimeters of fresh rabbit- serum" 
serum. 

To meet the second indication, the reader is referred to the 
instructions given under the "^Management of Feeble \^itality of 
the Xewborn" (see page 168). 

FUNCTIONAL DISORDERS OF THE NEWBORN. 
URIC ACID INFARCT, ICTERUS, MASTITIS. 

Uric Acid Infarct. 
The urine of the newly born is clear immediately after birth, 
but turns turbid soon after and remains so for the first four or 
five days. It contains bladder and kidney epithelia, hyaline and 
epithelial casts, and a large quantity of urates. In consequence 
of the sudden alteration in the blood circulation there is an exces- 
sive excretion of nitrogenous metabolic products, and, as the 
newlv born consumes but verv little water during the first few ^, . 

"... ' . . ^ Lric acid 

days of life, uric acid crystals and ammonium urate instead of crystals. 
being washed away are retained in the renal tubules. 

The symptoms accruing from this functional insufficiency 
depend greatly upon the degree of obstruction of the urinary 
tubules. Ordinarily gradual elimination of the uric acid and 
ammonium urate crystals occurs within a few days without any 
abnormal manifestations, except restlessness and crying just 
before and during the act of urination, and passage of small 
quantities of highly colored urine showing brick-red stains and 
a fine granular deposit on the diaper. Occasionally, however, Anuria, 
there are complete retention of urine, fever, and, owing to irri- Jion?^^^^" 
tation of the renal pelvis, nephritis with its concomitant symp- 
toms (albuminuria neonatorum). 

Treatment. — Large quantities of fluids, hot baths, mild 
diuretics. 

I?. Kalii acetatis 3ss ' 2 

Aq. foeniculi Siij \ 90 

M, Sig. : 3j every hour if necessary. 

Icterus Neonatorum Catarrhalis. 

The theories promulgated to explain the causation of icterus 
in the newborn are so numerous, pedantic and contradicting, that, 



184 DISEASES OF THE NEWLY BORN. 

for the sake of clearness, are best left alone. It is perfectly safe 
and sane to look upon this common (in about 80 per cent, of all 
ypera^c^my j^^^jy bom infants) and harmless phenomenon as an expression 
of the active physiological changes in the liver to which all the 
other organs are subjected in the first few days of life. It would 
seem, however, plausible to assume that analogous to catarrhal 
jaundice in older children, icterus of the newly born is also a 
enteric manifestation of gastrointestinal irritation, produced by the 

irritation. 111 1 1 i- • • r • 

sudden demand upon the digestive system to exercise functions 
hitherto not accustomed to. 

The yellowish discoloration of the skin usually appears on 
the second or third day, first on the face and chest and gradually 
extends to the abdomen and extremities and, rarely, also to the 

Afebrile , „ . . 

course, sclcrse. The icterus runs an afebrile, uncomplicated course of 
about two weeks' duration. Cases proceeding a more protracted 
course and presenting more or less severe general symptoms 
should always be looked upon as a partial manifestation of 
sepsis neonatorum (q.v.). 

Mastitis Neonatorum. 

Moderate swelling of the mammary glands of the newborn 
and discharge of a milklike secretion ("witches' milk") is phys- 
iological in infants of both sexes. It begins between the first and 
third weeks of life and may persist for weeks without giving rise 
to ill effects. Occasionally, however, as a result of traumatism 
Traumatism qj- infection it may terminate in acute inflammation or even sup- 

or infection. _ -' '^ 

puration. In this event the breasts are red, swollen and painful, 
and may present fluctuation at one or more points, and constitu- 
tional symptoms, such as restlessness, vomiting and fever. 

If the mammary glands are from the beginning not sub- 
jected to meddlesome interference, in short, are left entirely 
alone, there is usually spontaneous, gradual restitutio ad integ- 
rum. Should inflammation ensue, the breasts should be wrapped 
in oiled cloths or absorbent cotton lightly painted with tincture 
of iodin, or covered with emplastrum belladonnse smeared on 
soft thin leather. In the event of suppuration, if not relieved by 
^oTpus^ spontaneous evacuation of the pus, a radiate incision under asep- 
tic precautions is indispensable. 

Phlegmonous inflammation and gangrene are rare complica- 
tions, while atrophy of the mammary glands and more or less 
loss of function may prove very serious to girls. 



Spontaneous. 



Evacuation 



CHAPTER VI. 
Diseases of the Alimentary Tract. 



DISEASES OF THE MOUTH. 
STOMATITIS. 

This inflammation of the mucous membrane of the oral cavity 
is a more or less contagious affection peculiar to infancy and contagious. 
early childhood. It varies in intensity from simple temporary 
catarrh to fatal gangrene. It is invariably of parasitic origin. 
The degree of severity of the disease depends upon the patho- 
genicity of the parasite, the power of resistance of the patient, 
and the promptness and accuracy of the treatment. 

Stomatitis occurs, therefore, principally at a time when the 
child's health is undermined, as, for example, during dentition, or 
synchronously with acute infectious diseases. Even normally the 

. ...... Lack of 

mouth forms a favorable nidus for cocci, bacilli, spirilla, cleanliness. 
leptothrix, and like vegetations, and their growth is surely 
enhanced by allowing the child to enjoy its acrid nasal dis- 
charge ; to suck on dirty nipples, toys, and eatables ; by keeping 
its mouth and teeth filthy; by denuding the oral mucous mem- trauma. 
brane of its epithelium by brisk rubbing in the act of cleansing, 
and by permitting every friend or kin to infect the child's mouth 
by overinduls^ence in the art of osculation. Finally, dental caries, Dental 

•^ ..... canes. 

hemorrhagic affections, intoxication from the use of mercury, 
bismuth, etc., among many other diseased conditions frequently 
form contributing causes of stomatitis. 

In accordance with the seat and appearance of the lesion 
it is customary to distinguish the following varieties of the 
disease : — 

1. Stomatitis Catarrhalis (Erythematosa). — Redness and 

slight tumefaction of several portions of the mucous f^^^^^^ 
membrane of the mouth, coated tongue with prominent g^lfi^jng 
papilhe and red tip and edges. Often marked salivation. 

2. Stomatitis Mycotica (Soor, Thrush, Sprue). — Probably 

due to a hyphomycete, the Monilia Candida. Usually 
begins with a fine, white, flour- or casein-like deposit upon deposit.^^^ 

(185) 



186 



DISEASES OE ALIMENTARY TRACT. 



the slightly reddened tongue and buccal mucous mem- 
brane. If not arrested the dots and maculae coalesce and 
often extend to the pharynx, esophagus, stomach and 
intestines. This is apt to occur especially in atrophic 
children. 
3. Stomatitis Maculofibrinosa (Aphthosa, Follicularis, 
Herpetiformis). — The causal micro-org-anism is still 



Yellowish- 
gray or 
white 
specks. 




Fig. 52. — Ulcerative Stomatitis. {Sheffield.) 

undetermined. Often begins with small vesicles. The 
inflamed mucous membrane is here and there (usually 
anterior part of mouth) covered by small, grain- to 
lentil-sized, variously shaped, yellow, grayish-yellow, or 
grayish-white foci surrounded by a dark-red areola. By 
coalescence of several follicles large raised plaques are 
sometimes observed. Foetor ex ore. 
4. Stomatitis Ulcerosa (Stomacace). — It is attributed to the 
Bacillus fusiformis and the Spirochcete denticola. The 
lesion consists of numerous, grayish, irregular ulcers with 



DISEASES OF THE MOUTH. 187 

a bleeding base and angry-looking areola, situated at first Grayish 
on the red, spongy and painful gums, and, if not arrested, upo^n^red 
spreading to the tongue, cheeks or lips. Septic odor ex ^^^^' 
ore. 

This form of stomatitis differs from the yellowish to 
greenish, superficial, easily bleeding ulcers, known as 
Bednars Aphthce (ulcera pterygoidea), by the fact that 
the latter appear symmetrically on each side of the tion from 
median raphe near the junction of the hard and soft aphthse 

palates. "epithelial 

It may occasionally also be mistaken for the excep- ^^^^ ^' 
tionally ulcerating, so-called ''epithelial pearls/' These 
innocent milia-like dots, however, are usually found only 
in the newly born, and situated along both sides of the 
raphe of the palate. 
5. Stomatitis Gangraenosa (Noma Faciei, Cancrum Oris). — 
It occurs principally in cachectic children, chiefly between 
two and five years old. May follow ulcerative stomatitis 
or acute exanthematous diseases (measles!). Begins 
with a small, rapidly spreading, brownish, greenish ulcer 
upon a hard, elevated base, on the inner surface of the 
cheek, near the angle of the mouth or on the lips. Very 
soon a black spot appears on the outside of the cheek. Black spot 

outside 

surrounded by marked tumefaction of that side of the of cheek. 
face and of the submaxillary glands. The cheek becomes 
perforated, the edges of the wound turn black, and the Perforation, 
sloughing process spreads rapidly so that the whole thick- 
ness of the cheek has the appearance of a dirty, greasy 
scab, and within a few days may be completely destroyed. General 

\ ■ _ -^ •' r J J sepsis. 

Sepsis. Rapid exhaustion. 
Mild or even moderately severe cases of stomatitis rarely give 
rise to systemic disturbance, and unless the local lesion is situated 
on the lips, tongue, or gums and interferes with sucking or chew- ^'^^^^^ 
ing, several days may pass before the disease is detected. Some- J^eriookeT 
times the patient is feverish and restless, cries and refuses food 
in the earliest stage of stomatitis, but the constitutional symptoms 
do not stand in direct ratio to the extent and gravity of the local 
manifestations. Indeed, the reverse is often the case. However, 
with persistence of the local symptoms, sooner or later the 
general health participates in the pathologic process. Starch 
digestion is greatly impaired by the excessive loss of saliva, which 



188 DISEASES OF ALIMENTARY TRACT. 

almost incessantly dribbles from the swollen, reddened, half- 
closed mouth, and vomiting and severe diarrhea are frequent 
Involvement rcsults of swallowiug of the putrid saliva and the decomposing, 
tary tract, more or less ichorous and membranous oral contents. These lat- 
ter symptoms, in addition to the emaciation from refusal of food 
and absorption of septic material, greatly delay convalescence and 
* may lead to gradual or rapid exhaustion and fatal issue. In the 
absence of such grave symptoms and with early and careful treat- 
ment the prognosis is good in all forms of stomatitis, except 
noma (85 per cent, mortality). 

Above all, cleanliness should be enforced and the sooner it is 
begun with the surer we are of rendering the disease free from 
untoward consequences. Strictest cleanliness of the food, feed- 
ing-bottles and nipples, cups, spoons and everything else coming 
in contact with the child's mouth should be observed. The child's 

Gentle 

cleansing mouth should be regularly washed after each feeding, by gently 
wiping it with absorbent cotton dipped in a 2 per cent, watery 
solution of boric acid or bicarbonate of soda. As to general 
cleanhness see "Hygiene" (page 82). 

In mild cases it is usually sufficient to paint the affected parts 
once a day with a 2 per cent, solution of nitrate of silver and to 
employ the following mouth-wash every two to four hours : — 

IJ Boric acid, 

Borate of soda aa 3j 

Hydrogen dioxid, 

Glycerin aa 3j 30 

Alcohol 3iv 15 

Rose-water q. s. Siv 120 

M. Sig. : To be diluted with an equal quantity of water, as a 
mouth-wash. 

Should the stomatitis fail to yield to the treatment after 
twenty-four or forty-eight hours, more energetic measures should 
then be adopted to stay its destructive tendencies. The strength 
^^^sfive? '^^ ^^^ silver solution should be doubled, and the mouth irrigated 
every two hours with 1 per cent, permanganate of potash ; 5 per 
cent. Labarraque's solution, etc. 

It is often advantageous to suspend milk feeding for a few 

days and nourish the child on broths, light cocoa, cereals, toast 

and tea, pineapple juice, etc. Protracted illness demands active 

stimulation, stimulation by means of good wines (diluted), strychnine, and 

stomachics compound tiucture of cinchona. This may be combined with the 

rhubarb and soda mixture, to remedy gastrointestinal disturbance 



DISEASES OF THE MOUTH. 



1<S9 



which is ever present in cases of long standing. In the majority 
of instances even severe cases of stomatitis promptly respond to 
this mode of treatment. An exception to this rule is made, how- 
ever, by noma, — that rapidly advancing form of necrosis, which 
knows no barrier to its destructive, death-dealing trail, and often 
even the knife cannot stay its ravages. At the earliest possible 
moment the gangrenous portion should be destroyed with the 
caustic stick, nitric acid or preferably the actual cautery. Fre- 
quent cleansing of the parts should be continued day and night, 
and strengthening food and stimulants administered at short 
intervals. As Loffler's bacilli were found in a few cases of noma 
faciei and vulvae, diphtheria antitoxin (5 to 10,000 units) should 
be resorted to early in the course of the disease. Very often 
everything fails; fatal issue occurs either after two or three 
weeks (sometimes when the patient is apparently saved) or, 
more rarely, suddenly as a result of entrance of air into the veins. 
Radical operation has recently received enthusiastic advocacy. 



Fatality 
of noma. 



Diphtheri 
antitoxin. 



DENTITIO DIFFICILIS 
(Difficult Teething). 

As a rule, normal children get their teeth without any diffi- 
culty. They may show a slight indisposition in the form of fret- 
fulness, disturbed sleep and slight loss of appetite. If care is 
being taken not to overfeed the baby during this teething period 
and the mouth is kept free from outside infection, there is rarely 
any need for special therapeutic measures. On the other hand, 
infants of low vitality and more especially those who had been 
suffering from gastroenteric disturbances or rachitis previous to 
the eruption of a tooth, teething, particularly when several teeth 
come at once, is very apt greatly to aggravate the diseased con- 
ditions. But, even in these children, neglect in the general care of 
their health to a great extent is responsible for the serious con- 
sequences. Most people are so strongly imbued with the idea 
that teething is the sole cause of gastroenteritis, bronchitis, otitis 
and what not, and must be so as a matter of course, that they 
complacently wait and watch for the teeth to protrude and seek 
no medical aid to stay the ravages of the incidental ailments. It 
is usually in these cases that hyperpyrexia and convulsions are 
encountered, and that remedial measures have to be resorted to, 
as it were, to facilitate teething. 

Of course there are infants (see "Spasmophilia") who will 



Slight 
indisposition. 



Not the 
cause of 
all ills. 



190 



DISEASES OF ALIMENTARY TRACT. 



Careful 
feeding. 



get convulsions, high fever, etc., on the most trifling provocation, 
teething also contributing its share in this direction, but all these 
extraordinary manifestations are surely exceptional. 

The main thing, therefore, is to reduce the food, avoid 
"soothing syrups," which almost invariably contain opium and 
upset digestion, and to keep the child outdoors. 

Where the gum is very much swollen and the tooth is visible 
under the mucous membrane, lancing of the gum can do no harm 
and may hasten eruption of the tooth. 



stomatitis. 



DISEASES OF THE SALIVARY GLANDS. 
SALIVATION. 

Increased salivary secretion is almost physiological during 
first dentition, and is the result of increased blood-supply to the 
oral mucous membrane. Pathologically it is observed in stoma- 
titis, cretinism, helminthiasis and mercurial intoxication. Occa- 
sionally it is met in apparently healthy children long after first 
dentition, and in the absence of any discernible cause it is attrib- 
uted to a neurosis. In view of the harmlessness of the condi- 
tion per se no special treatment is indicated except protection of 
the chin and chest against the irritating effect of the constantly 
dribbling saliva, and removal of the causes wherever found. 



Obstructed 

salivary 

ducts. 



RANULA. 

Retention cysts, congenital or acquired, are not rarely 
observed in children, and are the result of obstruction of the 
salivary ducts. Most frequently a globular, usually unilateral, 
tense, cystic swelling is found on the floor of the oral cavity, 
sometimes close to the frenulum. This tumor, which is designated 
ranula, varies in size from a pea to a pigeon's ^gg and contains 
a thin or viscid fluid. If large in size, the tumor interferes with 
suckling, swallowing and breathing, and calls for its incision and 
cauterization, or complete excision. 

Ranula is not to be confounded with the peculiar sublingual 
^^^grp^th. growth (Riga's or Fede's disease) quite frequently observed in 
Italyi among nurslings. This neoplasm is usually situated at the 
insertion of the frenum linguae, attains the size of about a five- 
cent piece and shows a tendency to return "unless completely 
extirpated. 



1 Only a few such cases have thus far been observed in this country. 



DISEASES OF THE ESOPHAGUS. 191 

SECONDARY PAROTITIS. 

This form of inflammation of the parotid gland may occur in 
connection with acute infectious diseases. It differs from epi- 
demic mumps (g. v.) inasmuch as it is, as a rule, unilateral, 
heals spontaneously within a f ew^ davs, or ends in suppura- Tendency to 

■^ -^ ^ _ ^ \ ^ ^ ^ suppuration. 

tion, in the latter event requiring operative interference. 

DISEASES OF THE TONGUE. 

GLOSSITIS. 

Aside from the divers pathologic conditions of the tongue 
ordinarily met in connection wath stomatitis, tonsillitis, pharyn- 
gitis, exanthematous affections, etc., the tongue is subject to the 
following peculiar diseases : — 

1. Glossitis Marginalis Erythematosa. 

The inflammation is usually limited to the edges of the tongue 
which are red and partially denuded of epithelium. It is observed 
in artificially fed infants and probably the result of mechanical 
irritation in the act of sucking. 

The treatment is the same as for mild stomatitis. 

2. Glossitis Areata Exfoliativa (Annulus Migrans, 
Lingua Geographica). 

As a rule, it begins with a brownish thickening at the margin 
of the tongue and by gradual spreading forms irregular, circum- 
scribed lines, resemblino^, as the name indicates, a s^eos^raphical Denudation 

^' . ... of epithe- 

map. Now and then part of the thickened epithehum is thrust 
off, but new places are soon iuA'-olved, and in this manner the 
affection may go on for years, without, however, giving rise to 
ulceration of the tongue or any constitutional S3'mptoms. It is syphilitic. 
not, as was frequently supposed, a sign of syphilis. 

The treatment consists of cleanliness and occasional painting 
with a strong solution of chromic acid. (See also Stomatitis.) 

DISEASES OF THE ESOPHAGUS. 
ESOPHAGITIS. 

Primary inflammation of the esophagus is comparatively rare 
in children, since the principal cause of the disease in the adult, 
i.e., corroding of the esophagus by caustic poisons taken with 



lium. 



Not 



192 



DISEASES OF ALIMENTARY TRACT. 



Accidental 
injuries, 



Dysphagia. 



Stricture. 



Antidotes. 



Anodynes. 



suicidal intent, is of exceptional occurrence. However, it is occa- 
sionally met in connection with accidental injuries, such as impac- 
tion of foreign bodies, unintentional swallowing of caustics, etc., 
or scalding by hot fluids. The accompanying symptoms vary 
with the extent of the injury. They consist chiefly of dysphagia, 
tendency to vomit, and expectoration of bloody, membranous 
masses. In severe cases, if the patient at all survives (frequently 
fatal collapse) from the immediate effects of the injury, the 
esophagitis runs a very protracted course and produces secondary 
esophageal strictures (q. v.). 

Secondary esophagitis occurs as an extension of inflammatory, 
especially diphtheritic, processes of the mucous membrane of the 
mouth and pharynx. 

Antidotes in cases due to corrosives, morphine hypodermat- 
ically for the relief of pain and shock, ice collar to the neck and 
ice by mouth to subdue the inflammation, and stimulants when- 
ever indicated. 



Upper 

third of 

esophagus. 



Dysphagia; 

loss in 

weight. 



Dilatation 
by bougies. 



STENOSIS CESOPHAGI. 

Esophageal strictures may be congenital (q.v.) or acquired, 
the latter being the result of esophagitis (q.v.). Depending upon 
the severity of the injury the stricture may advance up to total 
atresia. In children the stenosis is most frequently situated in 
the upper third of the esophagus, and may occasionally be de- 
tected by esophagoscopy. Otherwise the diagnosis is established 
by introduction into the esophagus of an elastic catheter or whale- 
bone provided with small, olive-shaped steel tip. For this pur- 
pose the patient is placed in a sitting posture with the head 
extended slightly backward. The oiled instrument is guided 
with the first two fingers over the dorsum linguae and the epiglottis 
into the esophagus. 

In acquired stenosis the symptoms usually appear about two 
weeks after the injury, and consist chiefly of difficult deglutition 
and gradual loss of weight. In cases of stenosis due to compres- 
sion of the esophagus by diseased neighboring organs or tumors 
the symptoms are, of course, more gradual in their development, 
and more intricate in nature, agreeing with the primary cause. 

Partial stenoses often yield to dilatation by means of bougies, 
provided it is continued two or three times a week for at least six 
months. The bougie is left in place for from five to thirty 
minutes. Occasional introduction of the bougie after apparent 



DISEASES OF STOMACH AND IXTESTIXES. 193 

cure will prevent recurrences. Great care and patience are re- 
quired to prevent perforation. Gavage and nutrient enemata, if 
necessary. In severe and recurrent strictures operative interfer- operation. 
ence (esophagotomy or gastrotomy). Good results are claimed 
from the use of thiosinamin. Five drops of a 20 per cent, solu- Thiosinamin. 
tion may be injected hypodermatically twice a week, in addition 
to the dilatation previously spoken of. 

DISEASES OF THE STOMACH AND INTESTINES. 
General Remarks. 

The stomach is the most abused organ of the infantile body, 
Intended to serve as a recipient of only a sufficient quantity of infantile 
food to supply the needs of the human organism for its repair, 
maintenance and growth; destined by means of its juice and 
ferments to subdivide, assort and predigest the food consumed, — 
in short to prepare it for easy assimilation; and finally, created 
to macerate, filter and propel its contents into the channels best 
suited to complete wholesome metabolism; this very same stom- 
ach, regardless of its inherent powers, capacity, state of health, 
and actual size, only too often is filled to overflowing, forced 
to "churn"' almost incessantly, and to propel the food into the 
duodenum, frequently long before it is ready for reception. Dumping 
Nay, this very same stomach is rendered a dumping place, indigestible 
during meals, for everything on and off the table, and between 
meals, for "just a taste'' of over- or under-ripe fruit, anihn- 
dyed sweets and cakes, in addition to the bottle- or breast-feed- 
ings given merely as a "drink" to quench the child's thirst. 
What wonder then that gastroenteric disease is fiercely rampant, 
that the death-rate from intestinal aft'ections exceeds that of all 
other infantile diseases combined, and that those unfortunate, 
foully-fed children who survive remain dyspeptic, rachitic and 
decrepit, forming an easy prey to acute contagious and infec- 
tious diseases that usually befall the faint and the frail ! A'erily, 
considering the baleful acts of omission and commission in infant 
feeding, one is amazed by the ever-swelling hordes of youthful 
humanity that have apparently escaped the clutches of ignorance 
— and death. IMercif ul Nature ! 

With the recent advances in bacteriology and physiological 
chemistry and corresponding improvements in sanitation and 
infant-feeding, cows' milk no longer holds the record of 

13 



food. 



194 DISEASES OF ALIMENTARY TRACT. 

"Wuerg-Engel" (destroying angel) of the poor innocent babes. 
Indeed, seldom a case of gastroenteritis is met which is not pri- 
ciean milk manly traceable to some gross error of diet entirely independent 
°° slbie^or of the cows' milk feeding. The sooner the physician will appre- 
ciate that fresh, unpolluted, properly modified (as to quality and 
quantity), well kept, and regularly administered cows' milk is not 
inimical (excepted are of course the comparatively rare cases of 
so-called "cows' milk idiosyncrasy" from birth) to good health 
and perfect development of the child, the better will he be pre- 
pared to reveal the etiologic factors of the gastrointestinal dis- 
turbance and combat them! 

On the other hand, cows' milk, especially in the hot season of 
the year, whether contaminated at the dairy or at the filthy shop 
of the remorseless vendor, like water, may form an excellent 
vehicle for dissemination of pathogenic bacteria, and for the 
transference of infectious gastroenteric affections. 

Whatever the vehicle of transmission, — be it decomposed 
Danger in milk, f ruit, vegetables, or meats ; infected water, feeding-bottles 

infected . ...,., 

milk and or uipplcs, cups or spoons, toys or fingers ; infectious discharges 
articles from the mouth or nasopharynx, etc. — careful investigation has 

of food. 

established the fact that most, if not all, acute gastrointestinal 
diseases are primarily or secondarily due to microbic invasion of 
the alimentary canal, the severity of the affection more or less 
corresponding to the pathogenicity of the invading micro- 
organisms. 

The bacteria responsible for the production of gastrointes- 
tinal diseases are very numerous. Streptococci, the bacillus coli 
communis; the dysentery bacilli of Shiga, Kruse and Flexner; 
staphylococci, influenza bacilli, the bacillus pyocyaneus, and pro- 
teus, among many others, contribute their share as etiologic 
factors. The determination of the specific germ of each type of 
gastrointestinal diseases, however, is still a matter of experi- 
mental research and subject to great diversity of opinion. 

Gastroenteric disorders in breast-fed babies may occur, in 
^^dietfn addition to errors of diet and exposure to infection — less fre- 
^^!Sfa'n?s^ quent causes than in hand-fed babies — as a result of disturbance 
of the quality of the breast milk by disease, fright, grief, priva- 
tion, pregnancy, and like influences on part of the mother, or 
wet nurse. 

Finally, even in most carefully fed infants, gastrointestinal 
disorders are accasionally encountered where the alimentary 



incapacity, 



Misleading 
classification. 



DISEASES OF STOMACH AXD IXTESTIXES. 11)5 

canal is functionally or anatomically defective from birth or 
where the infant is sullering from diseases of the other organs congenital 
of the body,, or is indisposed from the effects of functional or 
organic alterations associated with normal bodily development 
{e.g., dentitio difficilis!). 

GASTROENTEROCOLITIS 
(Dyspepsia, Cholera Infantum, Summer Complaint). 

The more critically one analyzes the etiologic factors and 
pathologic data of the common gastroenteric diseases of early 
childhood, the more threadbare and misleading appear the exist- 
ing "text-book" classifications of these aff'ections. It is to be 
regretted that modern authors still tenaciously cling to and elo- 
quently dilate upon the subdivisions of ''gastritis,'' "enteritis," 
"colitis," "gastroenteritis." "enterocolitis." and what not. claiming 
separate and independent existence for each and every one of 
them, whereas, in reality, neither the clinical signs of a typical 
case nor the post-mortem findings warrant such an assumption. 

r-^ ^ • - 1 1 1 • . • -^ Incongruity 

On the contrary, one is otten amazed by the poignant incongruity between 
that prevails between the scarcity and mildness of the post-mortem and post- 

r ^• 11 • ' - 1 • • • - ■ mortem 

nndmgs and the extreme gravity ot the mtra-vitam mamtestations findings. 
of gastroenteric disease in early childhood, and licc z-crsd. 

A\'e are inclined to look upon the aforementioned group of 
gastrointestinal disorders as mere stages of one and the same 
pathologic condition, and will endeavor to discuss the subject in 
question from this point of Adew. 

1. Acute Gastroenterocolitis. 

Occasional vomiting and diarrhea, occurring as a result of 
unusual overloading of the stomach, too hasty feeding, partaking 
of indigestible articles of food i peels and parings') or foreign 
bodies, exposure to sudden atmospheric changes and undue 
excitement, etc.. are not rarely observed in otherwise apparently 
healthy, well-nourished children, and if of brief duration, are of 
no special clinical significance. These attacks may even be accom- 
panied by fever, mild cerebral irritation, colic, etc.. and yet 
remain outside the domain of pathology, or represent an aft"ec- 
tion which is generally spoken of as simple indigestion or the 
first stage of gastroenterocolitis. By avoiding further trans- firgj^sfage^" 
egressions of the ordinarv dietarv and hvHenic rules, and bv 



196 ' DISEASES OF ALIMENTARY TRACT. 

removing the causal obnoxious influences recovery is usually 
prompt and permanent. 

If, however, the vomiting and diarrhea persist or recur at 
frequent intervals ; if the child loses its appetite and some of its 
weight; if its tongue becomes heavily coated, its abdomen greatly 
distended and its general health more or less seriously impaired; 
if the infant suffers from severe abdominal pain after each feed- 
ing and vomits part of the food consumed and some mucus and 
bile; finally, if the stools rapidly increase in number and consist 
of masses of undigested food, of bad color and offensive odor, 
second a symptom-complcx develops which represents the second stage 
of gastroenterocolitis and is generally described as gastrointes- 
tinal catarrh or dyspepsia. 

Ordinarily these manifestations set in insidiously and if not 
promptly arrested grow worse gradually, arousing little if any 
anxiety on the part of those in charge of the baby, or are lost 
sight of, sometimes because of coincident "teething" (with the 
Gastroentero- laity the presumptive cause of all ills), until there is a sudden 
third stage, aggravation of the condition — supervention of the third stage of 
the disease. 

In this stage gastroenterocolitis assumes a very acute course. 
It is manifested by violent vomiting, excessive thirst; frequent, 
thin, watery, brownish, greenish, and later colorless or blood- 
stained stools. The vomitus is acid in reaction, bile-stained, and 
offensive in odor. The bowel movements vary between ten to 
fifteen in twenty-four hours, are preceded and followed by grip- 
ing pain and tenesmus. The child is very restless, feverish, sleep- 
less, and, with the symptoms persisting a few days, rapidly loses 
in weight, and sinks into a state of collapse, followed by con- 
vulsions, coma and death. More favorable cases may improve 
under energetic treatment, or linger for weeks or months, fre- 
quently suffer from intense exacerbations of the attack, and, 
finally, either recover after tedious convalescence or die from 
inanition or complications. 

Closely allied to the gastroenterocolitis just described (though 
possibly differing as to the exciting micro-organism), and prob- 
■^^^°^for^m^ ably representing only a severer, ''fulminating" form of the same 
disease, is the so-called infantile ''summer-complaint" or cholera 
nostras s. infantum. It usually rages in epidemic form during 
epidemfc? ^^^ ^^^ summer months, especially among bottle-fed infants and 
those exposed to bad hygienic conditions, but occurs sporadically 



DISEASES OF STOMACH AND INTESTINES. 197 

also at other seasons of the year. As with other contagious and 
infectious diseases previous ill health serves as an active and 
favorable predisposing cause also in this destructive aftection, the 
acute and grave symptoms ordinarily supervening upon a latent 
period of indisposition of variable duration.. 

The attack ushers in suddenly with vomiting, diarrhea and coiiapse. 
prostration. The vomiting is more or less projectile in character 
and occurs especially immediately after drinking. The evacua- 
tions range between fifteen to thirty or more in twenty-four 
hours, are at first fecal in consistency and odor, but soon turn 
very watery, serous, light yellow or greenish in color, and occa- w^atery, 
sionally mixed with blood-streaked mucus. The abdomen is often and biood- 
trough-shaped and but slightly sensitive to pressure. The thirst stools, 
is intense ; the tongue dry, brown or black and cracked, irre- 
spective of the degree of temperature, which is rarely very high. 
Owing to the excessive loss of fluids the urine is very scanty and 
often contains a moderate amount of albumin. 

As the disease progresses the child perceptibly loses in weight, 
from hour to hour ; its face is pinched ; its f ontanelles, temples and 
eyes are deeply sunken; its extremities are cool and blue; the 
heart-beat and respiration barely audible — in short it is in a state 
of profound collapse. Apathy, somnolence, convulsions and emaciation, 
death then follow in rapid succession; the younger the child, the 
earlier, as a rule, the fatal termination. The latter is sometimes 
preceded by a state of hydrocephaloid — a condition variously 
ascribed to cerebral anemia or hyperemia, edema of the meninges cephaioid. 
and uremia, and presenting the following symptom-complex : 
First stage, fever, restlessness, jactitations, and insomnia, flushed 
face, strong and bounding pulse; second stage, subnormal tem- 
perature, cold extremities, feeble, irregular pulse and respiration, 
apathy, sopor and coma. 

The disease having reached this grave stage it offers a very 
bad prognosis; but few children manage to survive so violent an j^. ^ 
attack. Some of the few who do are apt to succumb later to mortality, 
complicating nephritis, pneumonia, cerebral sinus thrombosis, 
peritonitis and the like. 

Convalescence is very tedious even in the absence of compli- 
cations, and a great many children remain decrepit for life, 
chronic otitis media, xerosis of the cornea and panophthalmia 
often adding their share of misery. 

With such sad prospects in view after the gastrointestinal 



198 DISEASES OF ALIMENTARY TRACT. 

aflfection is fully established, the urgency of early and energetic 
prophylaxis and treatment can readily be appreciated. 

To prevent the graver forms of gastroenterocolitis we must 
promptly remove the causes and effects of the mildest symptoms 
Preventive of the discasc. Attention to every detail of rational feeding and 
personal hygiene and strictest cleanliness of the child's living 
rooms, feeding utensils, wearing apparel, and of all other things 
coming in direct contact with the patient are the surest means of 
prevention. As in the majority of instances the pathogenic bac- 
teria enter the infantile alimentary tract with infected milk or 
water, these should, especially in the summer months, be steril- 

Sterilization . i -i i n r i r • • 

of milk, ized or even boiled, regardless of the temporary arrest of gam m 
weight that is concomitant with such feeding — a puny baby on 
the lap rather than a fat one in the grave ! Weaning of the baby 
and other innovations during the hot summer months should be 
avoided. Lengthy voyages exacting prolonged disturbance of 
rest, sleep, and proper feeding should be interdicted. On the 
other hand, a sojourn in the country (inland, mountains, or sea- 
ofair. shore) should be encouraged. Last but not least in importance 
as a prophylactic measure is the practice of whole or partial 

Breast brcast feeding of infants under one year of age, unless counter- 
manded by definite contraindications. 

The active treatment should begin, as already suggested, with 
the earliest inception of the gastrointestinal disorder. Regula- 
tion of diet is our most efficient therapeutic measure, and is 
almost invariably attended by improvement in the child's condi- 
tion if it is begun with a few hours' starvation of the patient and 
prompt cleansing of the alimentary tract of its obnoxious con- 

Discon- tents. Feedins:, breast or bottle, should at once be suspended 

tmuance of . , . . . . 

°iiik. until such time as exigencies for resumption of feeding will 
demand. In the mean time, especially in the absence of strong 
contraindications, such as violent vomiting, the infant should 
receive small quantities of hot or cold pure water or a light 
infusion of black tea. Recurrent vomiting calls for prompt atten- 
tion especially because of its fearfully exhausting effects, but also 
because it greatly hinders in the administration of suitable medi- 
cation. Ordinarily vomiting can be controlled by ''ice-sand," 
minute doses of calomel with or without bicarbonate of soda or 
bismuth; bismuth and cerium oxalate; tincture of iodine (in %o 
of a drop doses, to be repeated every hour or two) ; silver nitrate 
(gr. Yioo) ; ^ sinapism to the spine or epigastrium, and if all else 



DISEASES OF STOMACH AND INTESTINES. 199 

fail, lavage. In hospital practice the order of these therapeutic 
suggestions is usually reversed, i.e., lavage is usually resorted to Lavage 
first, and as a rule with immediate relief to the patient. In enterociysis. 
private practice, however, one often meets with objections on the 
part of parents, and hence is obliged to primarily "medicate." 
Lavage should be supplemented by enterociysis and, with the 
vomiting checked, also by a small dose of castor-oil. 

This mode of treatment generally suffices to arrest gastroin- 
testinal affections of moderate severity. Where the diarrhea 
persists we are often called upon to administer an astringent Astringents. 
mixture like the following: — 

R. Bismuthi subcarbonatis, 

Mist, cretse comp., 

Syr. rhei aromat., 

Glycerin., 

Aq. menthce pip aa 3ij | 8 

Aq. destil q. s. ad ill] \ 60 

M. Sig. : One teaspoonful every two hours for a child one year old. 

The camphorated tincture of opium may be added for the 
relief of pain. After complete cessation of vomiting, wx may 
resume feeding, first with small quantities of toast- or barley- Cereals. 
water and, several hours later, diluted, sterilized cows' milk or 
breast milk. 

In fulminating attacks of gastroenterocolitis where the bac- 
terial toxins so violently overwhelm the infantile organism, pro- 
ducing intense shock, the treatment must be very prompt and 
more heroic. In the initial, febrile stage, after a single but 
thorough irrigation of the stomach and bowels the little patient is 

^ ^ ^ Morphine 

given one-fiftieth of a grain of morphine and one five-hundredth and 

^ _ ... atropine. 

of atropine hypodermically, is wrapped in warm blankets and 
sent outdoors — wherever a good breath of air is obtainable — 
preferably to the seashore. After responding favorably the treat- 
ment is followed up in the manner previously outlined for less 
severe cases. 

In the algid stage, where the child is at death's door — wasted, 
cold, blue, rigid and lifeless, in short in profound collapse — 
powerful stimulation is in order. Thus, a hot bath with brisk ^^^*- 
rubbing of the body; a hot, high enema (injected slowly so as to stimulation 
be retained), hot water by mouth, hypodermatic administration 
of sterile camphorated oil (8 drops of a 15 per cent, solution), 
strychnine (gr. %o to /4o)? caffein sodium benzoate (gr. j), or 
w^hiskey (gtt. x), and hypodermoclysis (1 to 6 ounces of a 



200 DISEASES OF ALIMENTARY TRACT. 

0.6 per cent, hot sterile salt solution). As the patient improves 
a milder course of treatment is, of course, resorted to. The 
physician should not be deceived, however, by those apparent 
improvements, as they not rarely precede fatal termination. 

2. Subacute and Chronic Gastroenterocolitis. 

Exhausted by the paralyzing action of the virulent bacterial 
toxins; wasted and weakened from the excessive loss of body 
fluids and the strict starvation diet enforced during the acute 
course of the disease, the little patient rarely, if ever, emerges in 
a state of health capable to exercise its digestive organs to their 
normal capacity. On the contrary, convalescence usually pro- 
ceeds at a very slow pace, and is frequently interrupted by 
milder exhibitions of gastrointestinal indigestion which, if not 
promptly yielding to energetic treatment, eventually lead to 
chronic involvement of the alimentary tract. 

The mucosa of the stomach and bowels, especially of the 
ileum and colon, undergoes gradual thickening, ecchymosis and 
ulceration. The mesenteric s^lands are more or less enlars^ed, 

Pathologic , . ,,,,,,., . , 

findings, and on cross-section partly red and partly yellowish gray m color 
and sometimes caseated. In very protracted cases the mucosa 
and its follicles are atrophied, and the lungs, liver and heart in 
a state of inflammation and degeneration. 

The bowel movements continue to be frequent (four or five 
times in twenty-four hours). The stools are thinner than 
normally, are mixed with particles of undigested food, mucus. 
Diarrhea, and blood. The abdomen is flat, sometimes deeply sunken, and 
through its thin and wasted wall one can readily palpate the 
greatly enlarged, "ropy," mesenteric glands. The child's appe- 
... tite is capricious, often rather very good, and contrasts strongly 
wei^\\^ with the persistent loss of weight. The tongue is coated and 
flabby, its edges are red and indented by the teeth or gums, and 
here and there covered by an aphthous deposit. Slight indiscre- 
tions in the dietary are promptly followed by vomiting and 
diarrhea. Chemical examination of the contents of the stomach 
discloses marked diminution of hydrochloric acid. 

The course of chronic gastroenterocolitis varies in individual 
cases. Some infants, especially those in whom the chronic affec- 
tion followed upon the acute form, who remained free from 
grave complications and retained some vitality, often unex- 



DISEASES OF STOMACH AND INTESTINES. 



201 



pectedly show marked improvement with the setting in of cooler 
weather, and regain their heahh fully within but a few weeks. 

In another group of cases recovery is less rapid. Improve- 
ment alternates with aggravation of the condition, but, finally, 
the infant extricates itself barely alive, with a load of sequelae 



Variable 
prognosis 




Fig. 53. — Gastroenterocolitis Chronica in a child 10 weeks old. 
Suffering also from Tetanism. (Sheffield.) 



(e.g., rachitis) which keep it in a state of decrepitude for many 
years after, and not rarely for life. 

In still another group of cases all therapeutic efforts utterly 
fail to effect a cure. The child's face has a pallid, earthy tint, 
and senile expression ; the skin is dry and hangs in folds ; the 
fontanelles and temples are depressed, and after a period of 
several weeks or months the infant finally succumbs either slowly 



Grave 
symptoms. 



202 DISEASES OF ALIMENTARY TRACT. 

with symptoms of cerebral anemia and heart-failure or suddenly 
during an attack of eclampsia. The fatal termination is fre- 
°°^tions" quently enhanced by complicating pulmonary (passive- or bron- 
cho-pneumonia) and renal (colicystitis, pyelitis, etc.) affections; 
skin (ecthyma, furunculosis), ear and mouth infections, or inter- 
current acute communicable diseases (exanthemata). 

At best the prognosis is very grave (30 per cent. mortaHty), 
especially so in infants reared under bad hygienic conditions, in 
want and misery, and in those born with lowered vitality and 
congenital defects. 

However, no effort should be spared to save an infant that is 
apparently hopelessly lost, for just in chronic gastroenterocolitis 

Unexpected , . , , , 

recovery, the Unexpected sometimes happens — recovery takes place at a 
time when relief by death is prayed for. 

The patient should be removed from unsanitary surround- 
ings and intrusted to the care of someone who would obey 
orders and not use her own judgment and that of the many 
"good and experienced" neighbors. Be it remembered that only 

Change of too often chang^c of nurse (with her g^ross neelis^ence and stub- 
nurse. CO 

born interference) has saved many a hapless baby! Regulation 
Regulation of diet is iiiost essential. No hard and fast rule, however, can be 

of diet. 

laid down in this direction. We must feel our way in every 
individual case. It is always a good plan in bottle-fed babies to 
begin treatment with discontinuance of the milk for a day or 
two and thorough cleansing of the alimentary tract by lavage and 
enteroclysis. In the mean time the patient should be fed on thin 
barley-water, a light infusion of black tea, albumin-water, and, 
perhaps, a small quantity of freshly boiled, fat-free chicken 
soup. As soon as the stools diminish in frequency and improve 
in consistency, we resume milk-feeding in very high dilution. 
For a child let us say six months old we prescribe one teaspoonf ul 
of milk to seven teaspoonfuls of barley- or rice-water, to be given 
every three hours, and direct daily to increase the quantity of 
milk until the percentage of one to three has been reached, and 
then gradually to augment the total quantity at the last ratio 
{i.e., I to 3), until six ounces are obtained for each feeding. 
Should the milk mixture disagree, a weaker milk mixture is 
resorted to, or milk is again discontinued, falling back upon 
cereals, albumin-water and tea. Some infants do well, at least 
for a time, on condensed milk and barley-water ; others, especially 
those suffering from the so-called "fat-diarrhea," improve rapidly 



Cereals, 

later with 

milk. 



DISEASES OF STOMACH AXD IXTESTIXES. 203 

on skimmed milk or whey, and still others (older ones), who can- whey in 

•^ ^ ^ fat diarrhea. 

not tolerate milk in any form, get along on toast and tea, cocoa in 
water, mashed potato with beef juice or chicken soup, soft-boiled 
egg, custards and similar semisolid articles of food. In a great 
many instances "malt-soup," prepared in accord with the direc- Mait-soup. 
tions of Keller, acts admirably, both as a tissue builder and to 
check the protracted diarrhea. Last in line, but foremost in 
importance, is the fact that a complete cure of chronic gastro- 
enterocolitis in bottle-fed infants is almost invariably effected by 
a prompt change from bottle- to breast-feeding. 

The medicinal treatment of chronic gastroenterocolitis is 
chiefly symptomatic. Wliere vomiting persists, lavage (with 
warm boric acid solutions) should be practised daily or every 
alternate day, and continued for a few weeks. Digestion may be 
aided by means of pancreatin and diastase, and the appetite 
improved by small doses of tincture nux vomica and cinchona. Enterociysis. 
The patient should be given daily a high intestinal irrigation, 
either with one quart of plain hot (105° F.) water, 2 per cent, 
of bicarbonate of soda, or, where the lesion is localized principally 
in the lower bowel — as indicated by predominance of blood and 
mucus in the evacuations — with %o P^^* cent, solution of nitrate 
of silver. Where the diarrhea persists notwithstanding progres- 
sive improvement in the g^eneral condition of the patient, the 

. . . , . . .. Tannates. 

newer tannm preparations {e.g., tannalbm, tanmgen) are very 
serviceable. The tannates mav be combined with some bis- 

^ . . . . . , Bismuth. 

muth preparation {e.g., subgallate ot bismuth gr. ij to iv), to 
enhance the astringent eff'ects. 

Change of air (seashore), strict cleanliness of the body, 
change of position and frequent picking up of the patient from 
its bed, and active stimulation (strychnine, cinchona, Tokay wine 
and champagne) are active preventives of serious complications. 

PROCTITIS. 

Inflammation of the rectum is usually secondary in character, 
and not rarely associated with gastroenterocolitis, dysentery, secondary 
oxyurides, and prolapsus recti, and less frequently with gonorrhea 
(vulvovaginitis, q.v.) and diphtheria. Occasionally it is the 
result of trauma {e.g., foreign body), and the effect of drastic 
cathartics. 

The principal symptoms of this aft'ection consist of tenesmus -p^^ggj^^g 
(sometimes also strangury), frequent discharge of blood, mucus. 



204 DISEASES OF ALIMENTARY TRACT. 

and pus, with little fecal matter, and more or less severe colic. 
Depending upon the primary cause of the disease, the discharges 
may contain different kinds of bacteria {e.g., ameba, gonococcus, 
Differentia- diphtheria bacillus, worms, etc.), a fact which should always 
hemor?hJids! be borne in mind before arriving at a diagnosis and resorting to 
purpura treatment. Proctitis should not be confounded with rectal fistula 
suscep^tion' or hemorrhoids, purpura hemorrhagica and intussusception. The 
treatment depends upon the underlying cause ; in the main resem- 
bling that of dysentery {q.v.). 

COLICA INFANTUM, GASTRALGIA, ENTERALGIA, 
NEURALGIA ENTERICA. 

Infantile colic is usually associated with a number of con- 
genital (gastrointestinal stenoses, etc.) and acquired (gastro- 
intestinal inflammations, etc.) diseases of the alimentary tract. 
Less frequently it is apparently free from organic underlying 
causes. This so-called ''idiopathic" form of coHc is a spasmodic 
affection of the intestinal musculature, the result of patholos^ic 

Digestive ... , . , , . , . , , 

disturbance, imtations which act by way of the peripheral cutaneous nerves 
or the sensory intestinal nerves. To avoid unnecessary repeti- 
tion, it may briefly be stated that anything capable of producing 
gastrointestinal disturbance may form the cause also of the said 
pathologic irritations. This occurs especially in premature 
incapacity, infants and in those whose digestive organs are not quite fully 
developed. 

Some babies, breast- or bottle-fed, begin to suffer from colic 
soon after birth, and do what you will, maintain their "record" 
for several months, — until, with gradual growth, the digestive 
organs attain their normal functions. Such "colic-babies," if 
reared without immediate strict supervision of a capable nurse 
or physician are apt very soon to contract a severe gastrointes- 
tinal disorder from the effect of the experimental efforts, in 
feeding and medication, on the part of all who sympathize with 
the "innocent babe." This habitual colic, which is manifested by 
continued fretfulness, sleeplessness, and ps end ohnlimis. (instinct- 
ive, eager desire for warm drinks which temporarily relieve the 
pain), is to be distinguished from acute intestinal colic (colica 
flatulenta), which is sudden in development and rapid in disap- 
pearance, the latter depending upon the time required to get rid 
of the gas or stool. During a severe attack of acute colic the 
child's face is spasmodically drawn and bathed in perspiration. 



Habitual. 



Flatulent. 



DISEASES OF STOMACH AXD INTESTINES. 205 

The patient refuses food, cries pitifully, and draws its legs upon 

the abdomen. The spasm sometimes extends to the other muscles spasms. 

of the body, leading to general convulsions, and exceptionally 

even to coma and fatal issue. Of course, in the great majority 

of instances, the termination is favorable, especially under prompt 

and appropriate treatment. 

In breast-fed infants attention to the health of the mother or 
wet-nurse — avoidance of excitement, regulation of the bowels, 
indulgence in outdoor exercise — and, in both breast- and arti- 

^ . .. f. . . . .. , r ^• -1 Prevention 

hcially led, prevention ot constipation and overfeeding ot the of constipa- 
infant are very efficient anticolic measures. Where repeated 
examination of the breast milk proves it to be too rich in fat or 
proteids, the infant should be given a few teaspoonfuls of water 
or of some other diluent immediately before each nursing, and the 
length of time for each nursing proportionately reduced. 

As long as the infant thrives, notwithstanding the colic, no 
very material changes in the feeding should be attempted, as too 
much experimenting often makes matters worse. 

In habitual as well as flatulent colic, heat, either in the form 
of fomentations (a few drops of turpentine in a quart of warm 
water), g-entle massas^e of the abdomen with warm oil. or warm Heat 

' ° ^ , _ , externally 

drinks such as chamomile-, fennelseed- or peppermint-tea, will be 
found to act well. In cases of acute colic this must be preceded 
by a warm-water enema to aid in the expulsion of the gas or 
stool. Of drugs the following preparations are worth trying: — 

Charcoal and magnesia, of each 1 or 2 grains one hour after 
feeding; mistura sod?e et menth^, X. F., 5 to 10 drops every ten 
minutes until relieA'ed; compound spirits of ether, sweet spirits 
of nitre, or camphorated tincture of opium in doses of from 2 
to 5 drops, to be repeated two or three times. In purely nervous 
colic asafetida often acts magically. The lac asafetida (55s to ^e^rec^m 
Oj of warm water) should be gently administered by rectum. 
The ammoniated tincture of valaria (gtt. v) and sodium bromide 
(gr. ij) are often equally efficient. As to the treatment of con- 
vulsions see page 554. 

Proper food, regular bowel movements, and fresh air are 
efficient prophylactic measures. 

Infantile colic should not be confounded with intestinal intus- differential 
susception, appendicitis, and biliary, renal (uric acid infarct!) diagnosis. 
or vesical calculi. 



and 
internally, 



Soda and 

mint. 



206 DISEASES OF ALIMENTARY TRACT. 



CHRONIC CONSTIPATION. 

Judging by the construction of the infantile intestines — their 
great length, the thinness and feebleness of their musculature, etc. 
— nature seems to have intended that infants as well as older 
children should be more or less constipated. Indeed, the popular 
belief that healthy children are usually constipated* is often 
corroborated by actual observation. Not infrequently, however, 
obstmate constipation gives rise to a number of disagreeable 
constU)atTon. symptoms (flatulcnce, anorexia, headache, restlessness, sometimes 
convulsions, proctitis, anal fissure, prolapse of the rectum, hemor- 
rhoids, etc.) requiring active treatment, a task often difficult to 
cope with in view of the uncertainty of the etiological factor of 
the underlying disease. 

The causes of habitual constipation are very numerous. 
Aside from the cases resulting from gross abnormal anatomical 
relations or diseases, such as the different varieties of atresia 

Congenital . . . . . .,,.,. -11 

maiforma- mtcstmi, rccti, or am; tumors; congenital dilatation with hyper- 
trophy of the colon; hypertrophy of the valvulse conniventes; 
hypertrophy of the so-called rectal valve; inflammatory adhe- 
sions ; congenital displacements, etc. — which will not be discussed 
here — constipation is ordinarily caused by faulty diet, atony of 
the bowels, and constitutional disturbances. 

Faulty diet is responsible for a great many cases of constipa- 
tion. This etiological factor is frequently potent also in infants, 
when the woman's milk contains too much or too little of one or 
more of the constituents of milk, or is -insufficient in quantity. 
In artificially fed infants the cause of the constipation will prob- 
Lack ably be found in the insufficiency of fat consumed. In some chil- 
dren constipation is due, on the one hand, to too early and persist- 
ent feeding with amylacea, and, on the other, to the consumption 
of food that does not stimulate peristalsis, such as an exclusive 
diet of milk, meat, eggs, etc., and no potatoes, bread, fresh vege- 
tables, etc. 

Atony of the intestines may be primary, congenital in nature, 

or secondary or acquired. The former variety can frequently be 

traced as an hereditary taint through several generations. Some- 

Muscuiar timcs there is, in addition to the muscular insufficiency, also con- 

msufficiency. ^ _ -^ 

genital weakness of the innervation of the intestines. The latter 
condition embraces also the form of atony usually associated with 
congenital diseases of the brain and spinal cord. Secondary or 



DISEASES OF STOMACH AXD INTESTINES. 207 

acquired intestinal atony is generally the result of repeated at- 
tacks of temporary constipation, gastrointestinal indigestion with 
fermentation, enterospasm,, arrest of peristalsis due to reflex Enterospasm. 
irritation of the inhibitory nerves of the intestines, acute inflam- 
matory processes of the intestinal canal with consecutive atrophy 
of the intestinal coats, constriction of the lumen of the bowels by 
temporary displacements (enteroptosis, hernia, etc.), habitual Hernia. 
suppression of defecation or attention to it at irregular hours, 
enemas with large quantities of fluids, etc. All these etiological 
factors produce intestinal atony by directly or indirectly distend- 
ing the lumen of the bowels and depriving the intestinal muscula- 
ture of its resilience and tonicity. The latter condition is also 
apt to follow the abuse of antispasmodics, while drastic cathartics 
may lead to atony by mechanically thinning the intestinal coats. 

In diflferent chronic diseases associated with general debility 
{e.g., rachitis) and loss of flesh; in diseases of the nervous sys- organic 
tem, such as locomotor ataxia, myelitis, meningitis, etc., the 
sluggishness of the bowels forms merely a symptom of the prin- 
cipal disease. Habitual constipation is often met in diseases of 
the heart, profound anemia, etc., as a result of venous stasis of 
the abdominal organs ; to the same cause is attributable also the 
constipation occurring in children who through deformity or 
otherwise are incapacitated to enjoy a sufficient amount of bodily 
exercise. 

The treatment of obstinate constipation in infancy and child- 
hood resolves itself, firstly, in arresting the causes instrumental 
in the production of the disease ; secondly, in the removal of the 
damage done during the continuance of the constipation — not 
quite as easy a task as some authors wish us to believe. Indeed, 
a good number of cases of chronic constipation are never cured, 
no matter what therapeutic means are being employed. Prevent- 
ive measures are, therefore, to be recommended early and car- 
ried out with precision. 

It is of primary importance to train the child to have a move- 
ment regularly every day. Proper habits are often easily formed ^'^fJJ^^^ 
if the child is put upon the chamber or chair invariably at the 
same hour. The first few days it may require local stimulation 
to defecation {e.g., introduction into the rectum of a small oiled 
syringe-tip). Similar means should be employed also with older 
children and particularly school-children, who are very apt to 
suppress nature's impulse to empty the bowels. 



208 DISEASES OF ALIMENTARY TRACT. 

Two main factors are instrumental in the expulsion of the 
rectal contents : Contraction of the abdominal muscles and the 
diaphragm, and separation or relaxation of the gluteal group of 
Suitable musclcs. If the seat of the commode is too high and the aper- 
°"^ ° ■ ture in the seat too wide no support is given to the tubera ischii, 
the gluteal masses are crowded together instead of separated and 
the descent of the floor of the perineum is much hindered. This 
impediment to defecation may be obviated by substituting a low 
seat on a nursery chair or closet or small vessel for the high one 
previously used. The child is thus enabled to accomplish this act 
in a squatting posture which is most favorable to thorough 
emptying of the rectum. 

Correction of diet is, of course, very valuable for the preven- 
Proper tion of habitual constipation, but does not always remedy the 
trouble. This is particularly true of cases of very long stand- 
ing, since here we are dealing with secondary atony following 
prolonged distention and enfeeblement of the intestines. With 
the introduction of the recent methods of percentage feeding and 
the employment of "top milk" as a base, and barley- or oatmeal- 
water as a diluent, the number of cases of obstinate constipation 
among bottle-fed infants, due solely to faulty feeding, has per- 
in fat. ceptibly diminished. Hence, the indication of these methods of 
feeding also as a corrective of constipation. In breast-fed infants 
attention should be directed to the improvement of the general 
nutrition of the mother or wet-nurse. Frequently, however, it is 
almost impossible to regulate the quantity of fat in breast-milk. 
In this event the deficiency in fat may be supplied by administer- 
ing to the infant, just before nursing, a teaspoonful or two of 
sweet cream. The addition of cream, malt preparations, butter- 
milk, honey, an extra supply of cooked or raw fruit and vege- 
Mixed tables to the regular "mixed-diet" is invaluable as a corrective of 
constipation also in older children. A glass of cold water on an 
empty stomach and at night before retiring is often very useful. 

Faithful compliance with the suggestions just made very 
often yields favorable results. In a certain percentage of cases, 
however, more active measures have to be resorted to and it then 
devolves upon the physician to select such therapeutic means as 
will not affect the general well-being of the patient. This indi- 
cation can most appropriately be met by the simultaneous employ- 
ment of a combination of the so-called physicochemical pro- 
cedures, consisting of massage, oil enemas and hydrotherapy, and 



diet. 



DISEASES OF STOMACH AND INTESTINES. 209 

occasionally, also, electricity. This treatment is more advan- 
tageously carried out in the evening, before the patient goes to 
sleep. The child is placed on a hard couch or mattress with 
head and thorax raised and legs sharply flexed at the knee-joint Massage. 
and somewhat rotated outward. The attendant stands on the 
left side of the patient. The manipulations are begun at the 
fossa iliaca sinistra, where the sigmoid flexure is situated and is 
frequently found to be a halting place for hardened feces. With 
the tips of the fingers of one hand (in older children both hands 
may be used, one hand being placed upon the other) the attend- 
ant makes gentle circular movements along this portion of the 
colon and at the same time exerts upon it considerable pressure 
downward toward the rectum. Without changing these move- 
ments the attendant slowly ascends as far as the splenic flexure. 
From here he gradually returns to the sigmoid. He now begins 
a new tour going as far as the hepatic flexure, and after gradually 
returning to the starting point he makes his final trip reaching 
the cecum and, in the manner just outlined, returns again to the 
fossa ihaca sinistra. These manipulations should be followed 
by rhythmical vibratory strokes over the entire abdomen, inter- 
rupted by a few pressure movements against the spinal column in 
the epigastric region. The treatment should last from six to 
twelve minutes. 

Instead of trying the massage, oil enemas, and hydrotherapy 
separately, it is certainly preferable to employ these three pro- 
cedures — the anticostive triad — simultaneously, as they do not , ,. ,. 

-^ ' -' Anticostive 

interfere with one another, but, on the contrary, are destined to triad— 

-^ ' massage, 

supplement one another in their beneficial effect. Thus, after oil /uemas 
, ... ^i^<^ hydro- 

completing the massage the little patient is turned upon his left therapy. 

side, and by means of a piston syringe half an ounce or more of 
oil is gently injected into the rectum and allowed to remain there. 
This is followed by the application around the abdomen of a 
Priessnitz compress, which should be left in place until the next 
morning. It will almost invariably be found that the patient's 
bowels will act either during or soon after the treatment or, at 
any rate, not later than the following morning. A three or four 
weeks' course of treatment will usually suffice to establish regular- persistence 
ity of the bowels provided the preventive measures suggested be- jJJgnT^*' 
fore are strictly adhered to. In some, very protracted, cases of 
constipation these procedures may be supplemented by the appli- 
cation of the galvanic or faradic current. One electrode is passed 

14 



210 



DISEASES OF ALIMENTARY TRACT. 



Divulsion 

in rectal 

involvement. 



Laxatives. 



successively over different portions of the abdominal wall, and 
the other electrode is placed upon any other part of the body. 

Proctologists frequently advocate divulsion of the sphincter 
ani as a sure cure of habitual constipation. I am not inclined to 
be quite as enthusiastic over it, except in cases of constipa- 
tion due to rectal disease, as, for example, fissura ani, recto- 
spasmus, etc. 

Finally, there is a class of cases of chronic constipation which 
resists all forms of treatment as regards a permanent cure, but 
may be considerably improved by alternately resorting to the 
therapeutic measures already enumerated as well as to drugs. 
In the selection of an evacuant the physician must be guided by 
the etiological factors and the individual peculiarities of the case 
in question. The indiscriminate use of antispasmodics as well as 
the ever-ready, "soothing" laxatives is to be strongly deprecated. 
Effective and comparatively harmless are the following remedies : 
Soap and glycerin suppositories, medicated cocoa butter supposi- 
suppositories. torics (with aloin and belladonna in spastic, or aloin and nux 
vomica in atonic, constipation), enemas with small quantities of 
glycerin or larger quantities of soap-water; internally magnesia 
usta, magnesia and rhubarb, compound licorice powder, castor- 
oil, extract of cascara sagrada, calomel followed by a mild 
saline aperient, and, in older children, the standard mineral salts 
or waters. 

Whatever the method of treatment employed, the establish- 
ment of a habit to move the bowels regularly at a certain time of 
the day should at all times be our chief aim. 



Round, 
red mass. 



PROLAPSUS ANI, PROLAPSUS RECTL 

If the prolapse is limited to the mucous membrane of the anus, 
the condition is spoken of as prolapsus ani ; if the lower portion 
of the rectum protrudes through the anal orifice, it is known as 
prolapsus recti. In prolapsus recti the protruding part comes 
down during defecation in the form of a round, or sausage- 
shaped, glistening, red or bluish red, frequently bleeding mass. 
In the beginning the mucous membrane slips back in its place 
spontaneously, or is easily replaceable and remains there until the 
next movement; in severe cases, owing to marked inflammatory 
thickening, reposition of the mass may be very difficult, and if 
replaced may immediately prolapse again. 



DISEASES OF STOMACH AND INTESTINES. 



211 



These conditions are very common in young children, the 
softness of the connective tissue and incomplete development of 
the muscular system serving as predisposing causes. The ordi- 
nary exciting causes are habitual constipation, protracted diarrhea, 
proctitis, rectal polypus, oxyuris, phimosis, vesical calculus, i.e., 
conditions in which the act of defe- 
cation or urination is attended by 
pressing, tenesmus or strangury. 
Protracted, paroxysmal coughing 
{e.g., pertussis), by its dov^nward 
pressure upon the abdominal con- 
tents, also serves as an etiological 
factor, and prolapsus recti is not 
infrequently associated with rachi- 
tis, probably due to the accom- 
panying muscular debility and con- 
stipation. 

The diagnosis can readily be 
made by inspection and digital 
examination. It is most apt to be 
confounded with hemorrhoids and 
rectal polypus. Rectal polypus is 
the most frequent cause of rectal 
bleeding in children, and appears 
at the anus as a dark-red, bean- to 
cherry-sized, roundish tumor with 
a bleeding surface. Digital exami- 
nation usually reveals that the 
polyp is attached to the rectum, a 
few centimeters above the sphinc- 
ter, by means of a short or long 
pedicle. 

Slight prolapse is readily amenable to reposition of the pro- 
lapsed mass (oiling and gentle pressure upward with the patient 
in knee-chest position) and strapping of the buttocks (in older 
children only before the act of defecation), in addition to prompt 
attention to the aforementioned etiologic factors. Severer cases 
call also for reduction of the local inflammation by occasional 
painting of the affected area with balsam of Peru or a 2 per cent, 
solution of nitrate of silver. If these measures fail the prolapsed 
mass should be treated by punctate or linear cauterization. 




Fie. 



54. — Prolapsus Recti. 
(Sheffield.) 



Diagnosis 
by Inspec- 
tion and 
digital 
examination. 



Differentia- 
tion from 
hemorrhoids, 
polypi and 
intussuscep- 
tion. 



Reposition 
and strap- 
ping. 



Nitrate of 
silver. 



Actual 
cautery. 



212 DISEASES OF ALIMENTARY TRACT. 

General tonic treatment not rarely succeeds where local pro- 
cedures fail. 

INTUSSUSCEPTION 
(Intestinal Invagination). 

Intussusception, or sliding of one portion of the intestines into 
the other, is an affection principally of infancy and early child- 
seat of hood. The commonest seat of the trouble is the ileocecal region. 
Thus, the proximal portion of the ileum with or without the cecum 
becomes invaginated into the colon. Less frequently the ileum 
slides into the ileum, or a part of the colon into the colon. The 
stranguia- immediate results of the invagination are agglutination of the 
impacted opposcd scrous laycrs and strangulation of the impacted portion 
of the intestine. If the latter is not soon relieved, gangrene, 
sloughing and spontaneous discharge of the cast-off piece of 
intestine occurs, — the continuity of the intestine being preserved 
by end-to-end adhesion. 

The disease sets in very suddenly. In the midst of apparently 

perfect health, the child suddenly shrieks from intense pain and 

Sudden presents other symptoms of severe colic which fail to yield to 

pain; ordinary anticolic therapeutic measures. The pain and restless- 

tenesmus. . 1,1 1 1 i- 1 1 1 

ness mcrease, the abdomen becomes greatly distended, and, 
accompanied by marked tenesmus, the child passes from the 
bowels at first small quantities of feces mixed with mucus and 
blood, and later pure blood. 

Digital examination discloses blood in the rectum — often long 

before any is passed with the stool, — and if the intussusception is 

colonic in form, frequently a round mass is observed high up in 

Mass in the rcctum. Exceptionally and late the tumor protrudes from 

rectum. . . . . . 

the anus. In ileocecal intussusception inspection and palpation 
reveal a round ''lump" or sausage-shaped mass in the right iliac 
region, and occasionally a depression below the tumor — owing 
to displacement of the cecum. The tumor is less pronounced in 
intussusception of other portions of the intestines. 

The severity of the onset is no criterion as to the further 
course of the disease. In a small number of cases the colic 
suddenly ceases, the child resumes his normal appearance, and 
exhausted from the agonizing pain he falls into a profound sleep, 
Spontaneous making Up apparently well — spontaneous improvement or re- 
covery by spontaneous reduction of the invagination has appar- 
ently occurred. In such a cure the trouble is not always at an 
end, for the intussusception is very apt to return after a shorter 



DISEASES OF STOMACH AND INTESTINES. 



213 



or longer interval. In another group of cases, after the grave 
onset, the disease may pursue a milder course. The vomiting, 
meteorism, and tenesmus abate in their violence; the dejecta lose 
their bloody consistency, and the colicky pain returns only after 
long pauses. After three or four days, a piece of gangrenous 
intestine, the intussuscepted portion, is discharged per rectum. Discharge of 
This process is always fraught with danger. The few patients pirtion.^^^^ * 
who survive frequently succumb to consecutive chronic gastro- 
intestinal catarrh, with or without intestinal stricture. In the 
majority of instances, the symptoms grow worse within twenty- 
four hours from the start of the attack. The vomiting becomes 
violent and stercoraceous, the pulse feeble, the extremities cold, 

1 • r 1 r • 1 1 1 1 11 Peritonitis; 

the expression oi the lace pmched, the eyes sunken, and unless collapse. 
the condition is promptly relieved, the child succumbs within 
from four to eight days to increasing collapse, not rarely pre- 
ceded by intestinal perforation and peritonitis. 

At all events the prognosis is very grave. The mortality 
ranges between from 50 per cent, and 80 per cent, in cases left 
alone or treated palliatively. On the other hand, with prompt 
surgical treatment the chances for recovery are by far better — 
about 65 per cent. The best results (75 per cent.) are obtained 
in cases operated upon within 24 hours of onset of attack. 

The treatment of choice, therefore, is obvious : Early opera- 
tive interference, — before extensive adhesions and gangrene of 
the bowel have taken place. Temporizing is fatal. However, 
before an operation is resorted to we must be quite certain that 
we are not dealing with acute peritonitis, appendicitis, or intes- 
tinal obstruction from other causes — with which diseases intus- 
susception is most apt to be confounded. 



Prompt 
surgical 
treatment. 



Differential Diagnosis. 



Characteristic 
Symptoms 


Intussusception 


Acute Appendi- 
citis 


Acute Peri- 
tonitis 


Strangula- 
tion 


Onset 


Sudden 


Variable 


Variable 


Sudden 


Tumefaction, its 










seat and nature. 


Most frequently il- 


McBurney's point. 


Distributed 


Local disten- 




leocecal region, 


Rigfidity of ab- 


througfhout 


tion of bowel. 




occasionally 


dominal wall 


abdomen, al- 


Chiefly at ab- 




round tumor in 




so local exu- 


dominal 




rectum 




dation 


rings 


Tympanites 


Moderate 


Absent 


Pronounced 


Slight 


Abdominal pain .. 


Intense, greneral 


Moderate, local 


Marked, gfen- 
eral 


Severe, gen- 
eral 


Constipation 


Late, preceded by 
frequent muco- 
hemorrhag-ic 
stools 


Early 


Late 


Early 


Fever 


Slig-ht 


High 


High 


Slight 


Collapse 


Early 


Late 


Early 


Early 



214 DISEASES OF ALIMENTARY TRACT. 

When the services of a competent surgeon are not obtainable, 
Copious an attempt may be made to reduce the invagination by copious 
injec ions. ij^jg^^^iQ^jg ^f ^v^^rm (100° F.) water into the bowels, or by air 
inflation. 

For the water injections an ordinary fountain syringe with a 
rectal tube, suspended about four feet above the level of the 
patient's pelvis, answers the purpose. Two to four quarts of 
water should be used. During this procedure the patient should 
be kept on his back with his buttocks raised about one foot above 
the level of the shoulders. Occasional inversion of the child is 
useful. 
Morphine For the rcHcf of pain and arrest of undue peristalsis, mor- 
atropine. phine and atropine hypodermatically ; to check vomiting, lavage ; 
to combat collapse, stimulants and external heat. Liquid, easily 
digestible food to sustain nutrition. Complications arising should 
be treated according to indications. 

In view of the obscure causes of this affection, very little can 
be accomplished in the way of prophylaxis. Avoidance of 
habitual constipation, drastic purgatives, and of violent exer- 
cise (rapid up-and-down motion) may prove efficient prophylac- 
tic measures. The relationship between invagination and poly- 
poid growths still lacks authoritative confirmation. 

APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

Until recently the prevalence of appendicitis in early child- 
hood was not taken very seriously by the profession at large, 
and, hence, either because of this skepticism, or for want of 
understanding of the pathology of the disease, a great many 
cases of acute or chronic appendicitis were either overlooked, 
erroneously diagnosticated, or newly discovered as "food fever," 

o^Soked^ "cyclical vomiting," and the like. Nowadays, the occurrence of 
appendicitis in children and even in sucklings is no longer 
doubted. On the contrary, in view of the frequency with which 
the vermiform process is found implicated in the course of severe 
infantile gastrointestinal disease, and its tendency by its relatively 
greater length and width to favor lodgment of foreign bodies 
(such as fecal concretions, worms, etc., which act as sources of 
infection), there is ample reason for the belief that appendicitis 
is — at least — as common in children as in adults. As in the 

^°^ndren! latter the severity varies from simple inflammation to fatal gan- 
grene, depending of course upon the type and virulence of the 



DISEASES OF STOMACH AND [NTESTINES. 215 

causative bacteria and the promptness with which it is discovered 
and treated. 

Pathologically the simplest form of appendicitis consists of a 
catarrhal inflammation of the appendix. Its mucosa and follicles inflammation, 
are reddened and swollen, and their secretion more abundant than 
normal. The lymphatics of the walls and of the surrounding 
structures are congested. Gradually the submucous and serous 
layers become involved and the appendicular lumen narrowed. 
In mild cases the obstruction in the appendix subsides, allowing 
the escape of the mucous and bacterial contents, and, with the 
exception of slight thickening and adhesions, rapid restitutio ad 
integrum takes place. 

In more severe cases the obstruction continues, the appendix 
becomes more and more distended, the mucous secretion purulent, 
the' muscular coat — owing to its effort to expel the appendicular ulceration. 
contents — thicker, hypertrophied, while the mucous membrane, 
as a result of pressure from within the appendix, undergoes 
gradual atrophy and ulceration. Even in this stage of the disease 
spontaneous recovery by encapsulation and absorption of the 
abscess is still possible. 

In the majority of instances, however, instead of being 
absorbed, the purulent content of the appendix gradually, or 
rapidly, increases in quantity, and finally perforates the over- 
distended, more or less ulcerated appendix. The escaping pus ^^matfon 
finds its way where there is least resistance — into the cecum, 
small intestine, rectum, urinary bladder, gall-bladder, diaphragm 
or into the free peritoneal cavity. The pus may also penetrate 
into the retroperitoneal cavity or externally, usually in the right 
iliac region. 

Sometimes the inflammation is almost from the start so 
intense that perforation and gangrene of the appendix, and Gangrene, 
escape of its virulent contents into the peritoneal cavity occurs 
before a diagnosis can at all be arrived at. In these cases it is 
not rare to find also old inflammatory adhesions, indicating that 
the patient had once before gone through an attack of appendi- 
citis (recurrent appendicitis), which probably was mild and has 
escaped attention. 

The great variability in the course and termination of the 
aforementioned pathological processes can readily be explained 
primarily by the difference in the virulence of the causal 
bacteria, no single type of which having thus far proved to 



216 



DISEASES OF ALIMENTARY TRACT. 



Bacteria in 
appendix. 



Predisposing 
causes. 



Vomiting. 



Abdominal 
pain and 
rigidity. 



Pain on 

extension 

of leg. 



Situation 
of appendix. 



be the specific etiologic factor of appendicitis as a whole or of 
any of its forms. The bacteria found in the inflammatory prod- 
ucts of the disease are principally streptococci, staphylococci, 
the bacterium coli, the pneumococcus, influenza bacillus, etc. It 
is not at all uncommon for appendicitis to develop in connection 
with pneumonia, influenza, gastroenterocolitis, etc., thus tending 
to prove its infectious character. Prominent etiologic factors 
also are : Retention of fecal concretions, foreign bodies (pins, 
fish-bones, cherry-stones, or orange-pits), intestinal worms, trau- 
matism, exposure to cold and wet, etc. Male children (being 
more often exposed to the last named causes?) are more fre- 
quently attacked by appendicitis than female. Constipation and 
dyspepsia serve as predisposing causes. 

Acute appendicitis may set in very suddenly or be preceded 
by premonitory signs consisting of frequently recurring attacks 
of dyspepsia, with colic and constipation. It is quite probable, 
however, that the dyspeptic symptoms are in reality the manifes- 
tations of recurrent catarrhal appendicitis of very mild type. 
Appendicitis once established, the little patient stops eating, is nau- 
seated, vomits, and cries because of pain in the abdomen. The 
latter is more or less rigid. The anorexia is usually complete, 
and, if the child is forced to eat, the food is sooner or later 
ejected. Infants may continue taking the bottle or breast, to 
quench the ever-present thirst. In very mild cases nausea may 
replace the vomiting, but the latter symptom is always present 
in moderately severe cases and is quite severe in grave appen- 
dicular involvement, especially when the peritoneum is impHcated. 
Pain, spontaneous and on pressure, is invariably present during an 
attack, but it varies greatly in severity irrespective of the patho- 
logic condition of the appendix. Sudden cessation of pain is 
supposed to signify mortification of the underlying structures, 
and, bence, looked upon as a bad omen. Young children are 
usually unable exactly to localize the seat of the pain they are 
suffering from; little reliance, therefore, should be placed upon 
their localization. On the other hand, pressure pain can readily 
be elicited, and, as a rule, is most intense over the region of 
the appendix, which in children does not always correspond 
with ''McBurney's point" — the appendix is often situated either 
higher up or lower down in the pelvis. Sometimes even infants 
indicate the presence of pressure pain by attempting uncon- 
sciously to ward off the examining hand, by placing their little 



DISEASES OF STOMACH AND INTESTINES. 217 

hands over the most painful spot. Rigidity of the abdominal 
wall forms a pathognomonic sign of the disease and proves of 
great help in the diagnosis of appendicitis to one familiar with 
the peculiar sense of resistance of the abdominal wall to pres- 
sure. As a rule, the abdomen is distended, but it may also be 
contracted and as hard as a board. On gentle palpation the 
rigidity yields sufficiently to permit the detection of tumefaction Tumefaction. 
— the underlying thickened appendix in catarrhal appendicitis, or 
the variously sized, hard or doughy, immovable mass, in appen- 
dicular abscess. In some cases the tumefaction may be seen to 
project beyond the normal level of the skin, and be felt in the 
rectum, a digital examination of which therefore should never be 
omitted. Appendicitis is ordinarily associated with complete 
constipation ; the attack may, however, be ushered in by diarrhea, Pseudo- 

. . . diarrhea 

or, rather, p sen do -d'mvrhea. — since the stool is derived chiefly from and consti- 

. ... pation. 

the lower part of the colon, superinduced by the sudden irritation 
within and about the appendix. As the disease advances, in con- 
sequence of pressure by the growing tumefaction in the pelvis, 
there may be severe tenesmus (as well as strangury) with or 
without a bloody discharge, — a symptom which is very apt to 
mask the diagnosis. The temperature is moderate, from 101° 
to 103° F. in catarrhal appendicitis, and as high as 105° F., in 
abscess formation. In favorable cases the pulse and respiration 
agree with the rise or fall of the fcA^er. Low temperature with 
a high, feeble pulse is considered a bad omen, an indication of 
profound sepsis. 

Diagnosis. — Cases presenting the aforementioned typical 
symptoms of appendicitis can be diagnosed as readily in the 
child as in the adult. In fact, owing to the thinness of the infan- 
tile abdominal wall, and the proportionately large size of the 
appendix, it is usually not difficult to palpate an inflamed appen- 
dix unless it be — as it sometimes happens — misplaced somewhere 
beyond the reach of palpation. On the other hand, there is often 
considerable difficulty to differentiate an appendicitis pursuing Differential 
a very violent course with marked tympanites, shock and collapse, 
from a grave attack of acute gastroenterocolitis, typhoid with 
perforation, intussusception, hernial strangulation and the like.^ 
Even in such cases careful analysis of the typical symptoms of 
the respective diseases rarely fails to lead to a correct diagnosis. 



lagnosis. 



1 See page 213. 



218 DISEASES OF ALIMENTARY TRACT. 

Course and Termination. — The severity or mildness of the 
onset of an attack of appendicitis bears no positive relation to 
Localization the further course of the disease. After the inflammatory pro- 
° matton" cess has, SO to say, localized itself, which occurs usually within 
the first twenty-four or forty-eight hours, in the majority of 
instances the physician is able to conclude what sort of a case 
he is deahng with. By that time he will find that in catarrhal 
appendicitis the vomiting Has partially or entirely ceased, the 
pain diminished, the abdominal rigidity lessened, and the tume- 
faction become less palpable. The child is able more easily to 
move about in bed, to have a few hours of comfortable sleep, occa- 
sionally to expel flatus, and to express a desire for food. Un- 
eventful recovery may now take place within ten days, i.e., as 
far as subjective signs are concerned. In the majority of cases 
some morbid anatomical changes remain in the appendix and 
adjacent structures, e.g., inflammatory adhesions, kinking, con- 
striction of the lumen, etc. The region of the appendix thus 
remains a locus minoris resist entice for life subject to recurrent 
attacks of inflammation and its sequelae. 

Sometimes after an apparently benign course of a few days' 

Recrudes- duration, either without discernible cause or as a result of gross 

cenceof error in diet, undue exercise, and the like, there is a sudden 

attack. ' ' ' 

change for the worse. The symptoms spoken of to occur with 
the onset return, sometimes even in more pronounced form: the 
patient vomits, has chills, headache, severe pulling and throbbing 
pain in the abdomen. The temperature rises, the pulse increases 
in frequency and tension, respiration is quick but superficial (the 
patient is afraid to take a deep breath or to cough owing to the 
increase of the pain with the descent of the diaphragm) ; the 
child is restless and sleepless, lies principally on his back with his 
right leg flexed (attempt to extend it aggravates the pain) and 
cries with pain on being moved about. Palpation reveals a dis- 
tinct oblong tumor, the distended appendix, which is very tender 
and gives rise to a gurgling sound on pressure. If the disease is 
not checked by operation the indurated mass enlarges, loses its 
circumscribed character, becomes more doughy in consistency, 
and dull on percussion, in short presents unmistakable signs of a 
form'auon^ fluid Content — an abscess. This clinical picture of suppurative 
appendicitis does not by any means follow only the catarrhal 
variety; on the contrary, quite often it is in full development 
within the first two or three days of the disease, and, if the 



DISEASES OF STOMACH AND INTESTINES. 219 

abscess is not promptly opened, it bursts, often giving rise to 
general peritonitis and quick death. More rarely the accumula- 
tion of pus occurs very slowly and gradually and even remains 
in abeyance for a period of weeks or months, during which time Encapsuia- 
the abscess becomes walled off from the general peritoneal cavity ab*scess. 
by inflammatory adhesions, and may finally be absorbed, or with 
recurrent attacks of appendicitis perforate the sac and wander 
in any of the neighboring structures, sooner or later leading to 
the grave symptoms previously spoken of. 

In another group of cases — fulminating^ gangrenous appen- 
dicitis, — the symptoms are extremely alarming right from the 
beginning of the attack. In the midst of apparent good health, symptoms, 
or preceded by slight malaise, vomiting, colic, prostration and 
collapse, follow one another in rapid succession, and often with- 
out palpable local appendicular tumefaction, or any other signs 
pathognomonic of appendicitis ; the typical picture of general, 
septic peritonitis is in its full sway, — sometimes within twenty- 
four hours (usually after from three to five days) carrying the 
little victim to the grave. In such cases post-mortem examination 
reveals either pre-existing appendicular abscess, sudden rupture 
of the pus-sac, and diffuse infection of the peritoneum, or slough- mortem 
ing of a gangrenous appendix, involvement of adjoining blood- 
vessels (thrombophlebitis) and general sepsis (pyemia). 

In view of the uncertainty of the course of the disease, 
every case of appendicitis should sooner or later be operated 
upon. This opinion is in accord with that held by the best ^.^^ ^^^ 
clinicians of this age. The profession is still divided, how- operation, 
ever, on the question of time, when operative procedures prove 
most propitious for the patient's uneventful recovery. In solving 
so difficult a problem, the physician must be guided : 1, by the 
condition of the patient, and 2, the progress of the disease. 

1. TJie Condition of the Patient. — It certainly would be folly contra- 

to operate on a child in a moribund condition, or on one syn- in<iications. 
chronously suffering from a systemic fatal disease per se, e.g., 
miliary tuberculosis, diabetes, grave heart or kidney disease, 
and the like. An operation should be deferred in infants under 
six months of age because of the lack of resistance of the patient, 
and in view of the fact that in very young infants spontaneous 
recovery (at least temporary!) by absorption of the pus, or 
rupture of the abscess in the rectum are by no means rare. 

2. Progress of the Attack. — Mild catarrhal appendicitis, with 



220 DISEASES OF ALIMENTARY TRACT. 

the first attack, progressing favorably during the first four 
days, may be left alone until the quiescent stage, when the 
appendix should be removed. Severe or recurrent catarrhal 
appendicitis failing to improve after the fourth or fifth day, or 
Indications sliowing incipient symptoms of suppuration (increased leucocy- 
immediate tosis!) should be Operated upon at once, or if for some reasons 
opera ion. ^^ operation cannot be undertaken, treated medically for a week 
or ten days longer, until the abscess has become circumscribed 
and encapsulated, when an operation should be performed with- 
out further delay. The same rule applies also to all cases of 
slowly developing suppurative appendicitis, the physician being 
constantly on the guard, however, for sudden threatening symp- 
toms of perforation, — in the latter event demanding prompt sur- 
gical interference. Finally, an immediate operation is imperative 
in all cases of perforative and gangrenous appendicitis, — procras- 
tination being almost invariably fatal. 

In advocating operative procedures I presuppose that a com- 
petent surgeon is within reach to perform the operation. Other- 
wise the patient will fare better under medicinal treatment, which 
though only palliative is nevertheless potent to tide over the acute 
symptoms — often to hold the patient alive long enough until the 
services of a competent surgeon can be enlisted. The discredit 
cast in various quarters upon the surgical success in appendicitis 
to a great extent is due to the fact that the statistics compiled to 
Results show the bad results of operative treatment of appendicitis em- 

greatly ^ . 

u*l^nthe ^^^^^ t^^ work of the competent and incapable surgeons ahke, 
skill of the failino^ to specify that the work of the incompetent is chiefly 

surgeon. . . . . . 

responsible for the mortality. It is one thing for a surgeon skill- 
fully to remove a purely inflamed appendix, and quite another 
to be able successfully to meet emergencies in badly complicated 
appendicular abscess or gangrene ! The sooner, therefore, the 
attending physician will appreciate the fact that in the majority of 
the promptly treated cases the prognosis of appendicitis depends 
solely upon the skill of the surgeon, the quicker will the mortality 
from this affection dwindle down to insignificance ! 

When a patient is seen early, it is advisable to administer one 
dose of castor oil or calomel with bicarbonate of soda, and to 
wash out the stomach and intestine, — to clean the alimentary 
canal of its contents. This should be followed by the occasional 
administration, in the form of suppositories, of very small doses 

Arrest of . , . , . , , , ., . 

peristalsis, of codcine or opium, to arrest peristalsis and to keep the child 



DISEASES OF STOMACH AXD INTESTINES. 221 

perfectly at rest and free from severe pain. No medication by ^Jn°b^?'^^" 
mouth ! During the acute stage of the disease, the constant appli- mouth, 
cation of ice is useful to relieve pain and arrest rapid progress 
of the inflammation. Thirst should be relieved by small quan- 
tities of water or tea, and as long as anorexia exists, no attempt starvation 
at forced feeding should be tolerated. An occasional teaspoon- '^^^^• 
ful of milk, beef-juice, or broth, will prove sufficient to sustain 
life for days. Any indiscretion in the diet is hazardous. More 
liberal feeding may be practised after subsidence of the acute 
symptoms, after repeated escape of flatus, or partly formed stool. 
Even then extreme caution is commended, limiting the dietary to 
slowly increasing quantities of milk, broths, albumin water ; in 
older children fresh soft-boiled Qgg, milk toast, small portions 
of fine cereals, etc. For marked flatulence atropine hypoder- 
matically. Stimulation by means of strychnine and normal saline 
solution, both subcutaneously, should be resorted to in accord- 
ance with indications. As the patient improves, medication in 
the form of stomachics, intestinal antiseptics and laxatives may 
be administered by mouth, and the supply of nutritious food 
increased, so as to heighten the patient's vitality for an early ^^^^ ^^ 
operation. Children convalescing from an attack of non-operated operation, 
appendicitis should not be taken to any resort where a competent 
surgeon is not within immediate reach. Danger always lurks 
behind a diseased appendix. 

PERITONITIS ACUTA. 

Acute, non-tuberculous, peritonitis is of rare occurrence in ^^^^ j^ 
children. It is occasionally encountered as a result of direct children. 
violence or in connection with infectious diseases (e.g., typhoid 
fever, scarlatina, diphtheria), appendicitis, pneumonia, vulvovagi- 
nitis and other pus foci. In the newly born it not rarely forms 
a partial manifestation of sepsis (q. z'.). 

Acute peritonitis usually sets in with very acute symptoms : intense 
Excessive pain and tenderness of the abdomen, rapidly develop- tympanites. 
ing tympanites, at first diarrhea, later constipation, scanty urina- 
tion or complete anuria ; sometimes distinctly localized exu- 
dation ; high fever, especially in the first few days, and feeble, 
rapid, and very poor pulse ; dry and brown tongue, anxious and 
pinched expression of the face, and, as the disease progresses, ^^^^^ 
collapse. The course of the disease varies. Hyperacute peri- 
tonitis ends fatallv usuallv in two or three davs ; moderatelv 



Grave 
prognosis. 



222 DISEASES OF ALIMENTARY TRACT. 

severe cases may last a week, and then either terminate in death 
or in gradual recovery. To the latter class belong also the cases 
in which the pus breaks through the umbilicus, rectum or bladder. 

At all events the prognosis is very grave. It is almost always 
fatal in the newborn, and in the cases resulting from intestinal 
perforation. Traumatic peritonitis offers the most favorable 
outcome, and local peritonitis with encapsulated abscess often 
yields to prompt and suitable treatment. 

The treatment, of course, depends entirely upon the underlying 
condition. It is justifiable to recommend an operation (lapar- 
otomy) in all cases of acute general peritonitis which fail to 
respond to medical treatment within forty-eight hours, and in 
those resulting from perforation of an abdominal viscus {e.g., 
intestinal perforation in typhoid). 

The medical treatment consists of perfect rest for the body 

and immobilization of the intestine. This may be secured by 

Morphine the hypodcrmic administration of morphine (gr. %o? ^oi" ^ child 

and atropine , . ., , i-- r •! 

hypoder- two ycars old) and atropme (%ooo)^ the application of an ice-bag 
or light turpentine stupes Lo the abdomen and discontinuance of 
any nourishment until vomiting has completely ceased. Vomiting 
is best arrested by lavage or minute doses of iodin. After 
arrest of vomiting feeding may very cautiously be resumed. 
Breast-fed babies may again be put to the breast and bottle-fed 
should receive small quantities of milk, gruel, beef-juice, Tokay 
wine, champagne, and, if improvement continues, light mixed 
Rectal diet. For excessive tympanites the long rectal tube may be tried, 
allowing it to remain in situ for hours at a time. Cases run- 
ning a protracted course often do well on daily local inunction 
of ung. hydrargyri (5^ a dram), and the iodids internally. 
Localized abscesses should be incised and drained. In slow con- 
valescence, a sojourn at the seashore will prove beneficial. 
(For Tuberculous Peritonitis, see page 366.) 

INTESTINAL WORMS. 

Worms gain entrance into the human system chiefly through 
the ova — consumed with food or water, or carried to the mouth 
by means of the fingers. We distinguish the following varieties 
of worms : — 

Oxyuris Vermicularis (Seat-, Thread-, or Pin-worm). — 
Small, white, thread-like, freely movable worm, one- 
fourth to one-half inch in length. Its chief seat is the 



INTESTINAL PARASITES. 



223 




Fig. 55. — Ox^-uris Vermicularis. Female and Male. 
• (After Leuckart.) 




Fig. 56. — Tsenia Saginata. a. Natural size of the worm at 
different sections, h, Head (with pigment canaliculi). c, Pro- 
glottides. (Partly after Leuckart.) {Lenharts.) 



224 



DISEASES OF ALIMENTARY TRACT. 



Invades 
appendix. 



Throat. 



Skin, 

heart, brain, 

and eyes. 



Severe 
anemia. 



Stubborn 
diarrhea. 



In liver 
and lungs. 



rectum, where it causes intense itching. It may also 
infest the colon, cecum, appendix and vagina (vulvo- 
vaginitis). 

Ascaris Lumbricoides (Roundworm). — Cylindrical, reddish 
gray in color, from four to ten inches in length. It 
resembles the earthworm in form. Its chief seat is the 
small intestine, but it may migrate to the stomach, gall- 
bladder (icterus), throat, etc., in t\)e latter event occa- 
sionally producing attacks of suffocation. 

Taeniae (Tapeworms). — They are segmented worms of 
variable size. They inhabit the intestine and develop by 
budding. 

(a) Taenia Mediocanellata s. Saginata, or the beef tape- 
worm. It is several yards long. The head presents at 
its middle a pit-like excavation and four anterior suckers. 

(b) Taenia Solium, or pork tapeworm. It is shorter than 
the former. It is provided with four suckers, one pro- 
boscis, and a wreath of booklets. After invading the 
human stomach the liberated embryos may wander to 
various portions of the body (skin, heart, brain, and 
eyes) and there develop into small vesicles (cysticercus) 
and lead to serious disturbances. 

(c) Bothriocephalus Latus, or fish tapeworm. Several 
yards long, possesses about 3000 segments, a flattened 
head with two shallow suction grooves. May be the cause 
of severe anemia. 

(d) Taenia Nana. About one inch long, possesses a head 
with four suckers and a wreath of booklets. May cause 
stubborn diarrhea. 

(e) Taenia Cucumerina s. Elliptica. From five to fifteen 
inches long; develops from swallowing dog-ticks that 
infest the hair of dogs and cats. 

(/) Taenia Echinococcus. It inhabits the intestine of the 
dog. The latter transmits the ova to the human gastro- 
intestinal tract through the mouth by licking, etc. The 
embryos develop chiefly in the liver and lungs, forming 
cysts. 
Symptomatology. — In times bygone the laity looked upon 
intestinal worms as the source of all evil, and even the physician 
was frequently inclined to hold the same view. As a matter of 
fact, worms, with but few exceptions, rarely produce very serious 



IXTESTIXAL PARASITES. 



225 




Fig. d7. — Taenia Solium. (After Leuckart.) 




Fig. }>d>. — Bothriocephalus Latus. a, \\'orm, in sections; 
natural size. h, Head: lateral and front views. (After 
Leuckart.) 

15 



226 



DISEASES OF ALIMENTARY TRACT. 



harmless. 



Pallor, 

capricious 

appetite. 



disturbances. Indeed, numerous round- and tape-worms may infest 
As a rule the human intestines often without any indication of their pres- 
ence until accidentally discovered in the stools. Among the signs 
which are otherwise said to indicate their presence are the fol- 
lowing: A pale complexion, black 
rings under the eyes, foeter ex ore, 
capricious appetite, picking at the nose, 
recurrent urticaria, colic, headache, 
vertigo, apathy, mydriasis, pavor noc- 
turnus, grinding of the teeth, and dry 
cough. Some authors claim to have 
observed divers neuroses, convulsions, 
chorea, trismus, epilepsy, amblyopia, 
strabismus, and the like. The majority 
of the reported cases of this sort, how- 
ever, do not bear close scrutiny and 
are readily traceable to other causes. 
The actual harm done by some of the 
worms has been mentioned under each 
heading. 

Diagnosis. — The diagnosis can read- 
ily be made by macro- and micro-scopic 
examinations of the stools and sputum 
(echinococcus booklets) for worms or 
their ova. The finding of intestinal 
parasites may be facilitated by the 
administration of anthelmintics. 

Treatment. — Santonin and calomel 
act very efficiently in thread- and round-worms. 

I^ Santonini, 

Hydrargyri chloridi mite aa gr. vj 1 0.4 

M. et div. in pulv. no. vj. 

Sig. : One powder to be given every morning, on an empty stomach, 
for a child 3 years old. 

To expel taeniae the following is a very useful combination : — 

I^ Ext. fil. mar. seth. ^iij 

Emulsi chloroformi 'a %- 

Emulsi amygdalarum Q- s. ad 3ij 

M. Sig. : Two teaspoonfuls as a dose for a child 3 years old, to be 
administered as follows : 

The day before the diet should be restricted to fluids. In the 
evening the patient is given a few pieces of salt herring, fol- 




Examina- 

tion of 

stools and 

sputum. 



Fig. 59. — Taenia Nana. 
a, The whole worm (X 
9). h, Head (X 50). c, 
Hooklet (X 300). d, 
Segment (X 50). e, Egg 
(X 125). (After L^Mc^- 
art.) 



INTESTINAL PARASITES. 



227 



lowed an hour later by a purgative (castor-oil or calomel). The 
next morning the male fern should be administered on an empty Mode of 
stomach followed within half an hour by a dose of castor-oil or tion of male 
calomel. If only part of the tapeworm escapes, and the other 
part remains inside, the torn end should by means of adhesive 
plaster be fixed to the buttocks, and another dose of the anthel- 
mintic administered until the rest of the worm has been expelled. 
The effect of anthelmintics by mouth is greatly enhanced by 
enemas of soapsuds and turpentine (oss to Oj) or a decoction 
of quassia wood. Quassia is very useful in pinworms, especially Quassia in 

. , .- pinworms. 

if followed by local application of gray omtment. In older chil- 
dren the fluidextract of male fern may preferably be given in 




\^ 



Fig. 60. — Taenia Echinococcus of the Dog. a, Tsenia. b, Hooklets. 
c, Membrane fragment. (After Leuckart.) 



capsule form. The rare attacks of asphyxia from roundworms 
are best relieved by turpentine administered by mouth or by 
rectum. 

ANKYLOSTOMIASIS. UNCINARIASIS 
(Hookworm Disease). 

Although prevailing in this country for many years past, this 
affection has only very recently, principally through the eft'orts 
of Dr. Charles W. Stiles, received due recognition as the 
"American murderer." It is practically endemic throughout the Endemic in 
South, but is met sporadically also in other States of the Union. 

The disease is caused by the hookworm which infests the 
human body either through the mouth (by swallowing of infected 
water or food), and through the skin, especially the skin of the 
feet (the larvae of the- worm gradually entering the circulation), 
and ultimately settles in the upper portions of the small intestines. 

The hookworm comprises two species: Ankylostomum duo- 
denale (old-world species), which is endemic, especially in Italy 
and Egypt, and Uncinaria Americana or Necator Americanus (the Uncinaria. 



the South. 



Ankylosto- 
mum. 



228 



DISEASES OF ALIMENTARY TRACT. 



new-world species). Both species measure from about % to 
% inch in length (the females somewhat larger than the males), 
but while ankylostomum carries on its head four hook-like teeth 
on the ventral side and two smaller vertical teeth on the dorsal 
side, the uncinaria has a dorsal pair of prominent semilunar 
plates or lips, and a ventral pair of smaller plates of similar 
nature. 

By means of its armed mouth the worm fixes itself to the 
intestinal mucosa, producing minute erosions and hemorrhagic 




Fig. 61. — Ankylostomum Duodenale. a, Male, b, Female, c, Head. 
d, Natural size. (After Leuckart.) 

Spots, and sooner or later a more or less severe catarrhal process 
in the alimentary tract. It is still a matter of diversity of opinion, 
whether the uncinaria feeds on the epithelial cells of the mucosa 
^^he blood ^^' ^pou blood. Howcvcr this may be, the blood certainly under- 
^perSicioul ^^^^^ marked changes, in severe cases, resembling the blood 
findings of primary pernicious anemia. Very soon other organs 
of the body are affected, especially the liver and spleen. 

Post-mortem examination usually reveals fatty degeneration 
of the liver; softening of the spleen and paucity in lymphoid 



pernic 
anemia. 



Stuuted 
growth. 



Pallor. 



Dropsy, 



INTESTINAL PARASITES. 229 

elements ; nephritic changes in the kidneys ; pallor of the lungs ; ^"o^j,^^^^^ 
flabbiness of the heart, and anemia of the brain and effusion into findings. 
the ventricles. 

Hookworm disease is most destructive in the young. Chil- 
dren remain stunted in physical and mental development ; they 
look old, tired, apathetic, and with puffiness of the face not rarely 
resemble cretins. The skin is sallow and the sclera white or 
bluish-white. They suffer from palpitation of the heart, dyspnea, 
headache, dizziness, tinnitus, nausea, occasionally vomiting and 
abdominal pain. The appetite is either poor or voracious, often p^^^- 
accompanied by a desire for unnatural food, leading to eating of 
earth, dirt, rags, etc. With increasing anemia there is frequently 
dropsy in the subcutaneous tissues and serous cavities — the 
edema often masking the emaciation and flabbiness of the body 
musculature. 

Occasionally the disease runs quite a rapid course, within a 
few weeks ending fatally from exhaustion. 

The diagnosis of hookworm disease is based upon a mac- 
roscopic and microscopic examination of the stools for the worm 
and its ova. 

Thymol acts specifically in this aft'ection. It may be admin- 
istered in an emulsion with acacia or, in older children, in the 
form of capsules, the thymol crystals being first triturated with 
sugar of milk. The following mode of administration is recom- '^^5'^^°^ 
mended : Late in the afternoon the patient receives 2 grains of 
calomel (no castor-oil!), and the next morning 1 dram of Epsom 
salts. After the bow^els have thoroughly acted 5 or 10 grains of 
the thymol are given on an empty stomach, and, if indicated, the 
dose repeated after an hour. The patient is kept in bed, without 
food, until late in the afternoon. 

The feces should again be examined for uncinaria after the 
lapse of from two to four weeks. 



Exhaustion. 



CHAPTER VIL 
Diseases of the Liver. 



ICTERUS CATARRHALIS 

(Catarrhal Jaundice). 

Catarrhal icterus (catarrh of the ductus choledochus) 

occurs as frequently in children over four years of age as in 

adults. It is comparatively rare in infants. As a rule, it is caused 

Gastro- by and associated with gastroduodenal catarrh, and begins with 

duodenal , i ^ • • • , ,. , . ^ 

Catarrh. coatcQ touguc, auorcxia, nausea, vomiting, and slight rise of 
temperature. Sometimes (epidemic icterus) the onset is sudden 
with high fever, apathy, delirium, headache and vomiting, so that 
before the appearance of the icterus cerebral disease is first 
thought of. In a day or two it is usually found that the urine is 
brownish yellow (bile-stained), the feces are gray and clayey, 
and the conjunctivae, sclerae and skin yellow in color. This path- 
ognomonic group of symptoms increases in intensity up to about a 
week, and then begins to diminish, first with clearing of the 
urine. The pulse is usually retarded, about seventy beats to the 
minute when the child is at rest. Palpation and percussion reveal 
tenderness over the stomach and liver, and occasionally some 
enlargement of the latter. This is particularly the case in 
catarrhal jaundice running a protracted course. 

The prognosis is favorable and under suitable treatment the 
symptoms ordinarily subside within from ten to fourteen days. 
The treatment consists of restriction of diet to thin soups, 

Regulation , , . . ^ 

of diet, albumin-water, skimmed milk, tea and toast, boiled fish or 
No fats, chicken, and similar, easily digestible food, free from fat (no 
cream, eggs or pastries!). Gradual return to a heavier diet. 
Medicinally, a few small doses of calomel and bicarbonate of 
soda, and daily intestinal irrigation (with 2 quarts of water, at 
90° F.) will usually suffice to arrest the disease. Pancreatin, 
rhubarb and soda mixture, and sodium salicylate are useful reme- 
dies, and prolonged warm alkaline baths (one-half pound of 
bicarbonate of soda to the bath) hasten recovery in chronic cases. 
(230) 



CIRRHOSIS OF THE LIVER. 281 

DISEASES OF THE PARENCHYMA OF 
THE LIVER. 

Primary disease of the parenchyma of the Hver is extremely 
rare in children under twelve years of age, since its principal 
cause — alcoholism — is practically unknown in young children. 
On the other hand, secondary involvement of the liver is not 
infrequently met in connection with syphilis, tuberculosis, chronic i^ connec- 

^ -^ . . . tion with 

suppurative processes, malaria, rachitis, valvular heart disease, chronic 
protracted gastrointestinal disease, and infectious fevers. In 
these conditions the symptomatology is the same as in adults. 

CIRRHOSIS OF THE LIVER. 

1. Atrophic Cirrhosis. — i\fter a prodromic stage of several 
weeks, consisting chiefly of gastrointestinal disturbances, emacia- 
tion, tympanites, ascites, slight enlargement of the spleen, and 
dilatation of the abdominal veins gradually complete the clinical 
picture of the disease. The atrophy of the liver usually sets in 
insidiously, as a result of gradual hardening and contraction of 
the connective tissue. The course of the disease is shorter in 
children than in adults. Hemorrhages from the stomach and nose 

and into the skin not rarely occur toward the end of the disease, Hemorrhages. 

'' _ _ Ascites. 

and progressive ascites hastens fatal termination. 

2. Hypertrophic Cirrhosis. — This disease is characterized 
by considerable enlargement of the liver, pronounced icterus, 

very marked enlargement of the spleen, and protracted course, icterus. 
Ascites is absent until very late. The children usually remain 
stunted in growth. The liver is of very hard consistence. 

3. Congestive Cirrhosis (Cardiac Cirrhosis, Cardiotubercu- 
lous Cirrhosis). — Pathologically it is characterized by hyper- 
trophy of the liver and spleen, obliteration of the pericardium, and Pronounced 
tuberculous pleuritis and peritonitis. Intense ascites forms the 
principal clinical symptom. 

4. Sugar-cake or Sugar-coated Liver (Pericarditic Pseudo- 
cirrhosis of the Liver — Pick's Disease). — This form of liver 
disease is closely allied to the former variety. It is a progressive, 
incurable affection of unknown etiology. 

Treatment. — As small quantities of spirituous liquors have 
proved to be the cause of quite a few cases of hypertrophic cir- 
rhosis of the liver in children, it is essential to interdict its use in , ,.^°,^'co" 

' holic stimu- 

children, unless intended for temporary therapeutic purposes. ^^'^*^- 

The iodids and mercury should be given a fair trial in all 



232 



DISEASES OF THE LIVER. 



forms of cirrhosis irrespective of cause. The ascites may be 
relieved by tapping, if diuretics, cathartics and heart stimulants 
fail to do so. Bland diet. Sojourn at the seashore. 



Absence 
of ascites. 




TUMORS OF THE LIVER. 

Benign as well as malignant 
tumors of the liver are occasion- 
ally observed in young children 
and even in the newly born. 
Cystic degeneration is most com- 
mon, and cases of carcinoma and 
adenocarcinoma, and more rarelv 
sarcoma are on record. These 
growths should not be confounded 
with gumma of the liver — the 
effect of specific treatment being 
most decisive in the diagnosis. 

AMYLOID LIVER. 

It is often associated with 
amyloid degeneration of the 
spleen and kidneys, and secon- 
dary tO' some wasting disease, 
especially chronic suppurative 
processes in the bones and joints. 
The hepatic and splenic dullness 
is enlarged, but pain on pressure, 
jaundice, or ascites are absent, 
unless the portal circulation is 
interfered with by enlargement 
of the glands in the portal fissure. 
Attention to the cause and dietetic and hygienic measures 
may prove effective to arrest the degenerative process. 



Fig. 62. — Primary Family 
Splenohepatomegaly. Same 
as Fig. 63. when 4 
younger. (Sheffield.) 



years 



Probably 
congenital. 



PRIMARY FAMILY SPLENOHEPATOMEGALY. 

This peculiar, apparently congenital, enlargement of the spleen 
and liver is occasionally encountered in two or more members of 
the same family. Although accurately described by Gaucher 
thirty years ago, and carefully studied since then in the 
living and post-mortem, its etiology is still shrouded in mystery. 



PRIMARY SPLENOHEPATOMEGALY. 



It IS generally overlooked in early nifancy, or the splenic and Large liver. 

, . 1 ' . ., , , . . , . . spleen, and 

hepatic enlargement is attributed to rachitis, splenic anemia or lymph-nodes. 
syphilis. As the child gets older it is found that notwithstanding 
good hygienic care and treatment the affected organs assume 




Fig. 63 Fig. 64 

Figs. 63 and 64. — Primary Family Splenohepatomegaly in 
brother and sister. (Sheffield.) 

greater dimensions, often occupying the entire abdominal cavity. 
In addition to this symptom the patient usually suffers from 
anemia and its accompanying manifestations ; occasional hemor- 
rhage from the nose and mouth ; pigmentation of the skin, and 
enlargement of lymph-nodes. The disease usually proceeds a 
chronic course and is sometimes marked by remissions or even 



Chronic 
course; 
usually fatal. 



234 



DISEASES OF THE LIVER. 



spontaneous arrest of further enlargement. In the majority of 
instances, however, death supervenes in from three to ten years as 
a result of passive congestion of the different adjacent organs 
which are displaced and pressed upon by the ever-growing spleen 
and liver. A correct diagnosis can usually be made by excluding 
syphilis (Wassermann reaction positive), tuberculosis (tuberculin 
Differentiation test positivc ! ) , splcuic anemia (liver usually free !), von Jacksch's 
anemia (distinct blood changes ; liver usually normal !) and Banti's 
disease (spleen but moderately enlarged; usually ascites; not con- 
genital). Early splenectomy is the only procedure that offers any 
prospect of recovery. Cases in which the splenohepatic enlarge- 
ment progresses very slowly are best left alone. 



from syphilis, 
tuberculosis, 
splenic anemia, 
pseudoleuke- 
mia and 
Banti's disease- 



Complica- 
tion of 
suppurative 
processes. 



Septic 
symptoms. 



ABSCESS OF THE LIVER. 

This condition is occasionally observed in children, most fre- 
quently as a result of extension of septic processes from neigh- 
boring structures, e.g., suppurative appendicitis, phlebitis umbili- 
calis, typhoid or dysenteric intestinal ulceration. It may follow 
traumatism, invasion by roundworms, suppuration of echinococ- 
cus cysts, or of the mesenteric glands. The abscess may per- 
forate into the thorax, intestines, or externally. 

Symptomatology. — Chills, hectic fever, tenderness over the 
liver, marked gastrointestinal disturbance, slight icterus, enlarge- 
ment of the liver, sometimes fluctuation and pus on aspiration. 

Treatment. — Free incision and evacuation of the pus as 
soon as the diagnosis has been established. 



Differential Diagnosis. 





Liver Ab- 
scess 


Hydatid Cyst 
OF THE Liver 


Pleurisy with 
Effusion 


Solid Tumor 
OF THE Liver 


Chills 


Marked 
Hectic 
Marked 
Sligfht, early 
Moderate 

Higfhest in mid- 
axillary line 
Pus 

Absent 


Absent 
Absent 
Absent 
Late 

Pronounced "hy- 
datid vibration" 

Higfhest in mid- 
axillary line 

Non-albuminous 
fluid with "hook- 
lets" 

Absent 


Sligfht 

Moderate 

Absent 

Absent 

Absent, diffuse flat 
area, uninflu- 
enced by inspira- 
tion 

Lowest in mid- 
axillary line 

Albuminous fluid 
which coagfulates 
on boilingf. Pus 
in pyothorax 

Present 


Absent 


Fever 


Absent 


Tenderness 

Icterus> . . . . 


Moderate 
Marked, late 


Fluctuation 

Dullness 


Absent 
Irregular 


Aspiration reveals 
Lungf symptoms... 


Blood 
Absent 



CHAPTER VIII. 
Diseases of the Respiratory System. 



GENERAL REMARKS. 



The inherent frailty of the infantile respiratory tract is very 
conducive toward its morbidity. The nasopharyngeal passages inherent 
being very narrow and winding — intended to halt air impurities acquired 
and to moisten and warm the inspired air before its entrance to naso- 
into the larynx — functionate to their own detriment in localities catarrh. 
where the air is dust-, smoke- and dirt-laden, and where atmos- 
pheric changes are many and marked. Thus, the child being 
unable to clear its nose, the detained foreign bodies irritate the 
delicate, highly vascular mucous membrane, before long forming 
a nidus for bacterial invasion. As we will see later "a cold in the 
head" is quite common in infants, and, while per se harmless in 
its immediate effect, is often serious in its remote results. The 
local congestion by its repeated recurrence produces a locus 
minoris resist entice not alone of the mucous membrane of the 
nose, but, by extension and persistence of the inflammatory 
changes (hypertrophy), of the pharynx and adenoid tissue 
as well. With ensuing nasopharyngeal obstruction breathing 
now proceeds principally through the mouth ; the air no longer 
undergoes the preparatory process of filtration, moistening and 
warming, but reaches the larynx in its impure, irritating state, 
sooner or later giving rise to a catarrhal inflammation of the 
larynx and neighboring structures. This condition is soon aggra- 
vated by the continuous affluxion of foul nasopharyngeal secre- Extension 
tion, and by the inability of the little patient to clear its throat °^ inflam- 

' -^ _ -^ ^ ^ mation to 

by forceful expectoration. Furthermore, the thorax being^ short bronchi and 

■^ r ' o pulmonary 

and narrow, its musculature thin and feeble, and the heart and aiveoii. 
thymus gland comparatively large, the more or less compressed 
lung is greatly hampered in free aeration and in ridding its 
distantly located portions of the obnoxious inflammatory prod- 
ucts. Hence the pertinacity of apparently insignificant pul- 
monary lesions, the frequency of unresolved pneumonia and 
pyothorax, and the insidious development of asthma, atelectasis 

(235) 



236 DISEASES OF RESPIRATORY SYSTEM. 

and emphysema. As the child grows older, the nasopharyngeal 
tract larger, the thoracic cavity more spacious and, synchronously, 
the respiratory function more forceful, there is a corresponding 
reduction in frequency and persistency of respiratory disease, 
notwithstanding, or, perhaps, because of the increased exposure 
of the child to atmospheric changes and infection. 



DISEASES OF THE NOSE, THROAT AND EAR. 

RHINITIS ACUTA 
(Coryza). 

Acute coryza is a frequent affection of childhood. It may 

occur primarily as a result of bacterial infection following ex- 

Primary posure to thermic, mechanic or chemic irritation, or secondarily 

secondary, in association with measles, influenza, scarlatina and diphtheria. 

Primary coryza (with sneezing, slight rise of temperature, 

anorexia, etc.), while quite harmless in older children, is often 

Sneezin Very scrious in infants. Here it usually begins with vomiting, 

fever, and sometimes convulsions and occlusion of the upper air 

H ersecre- P^ssagcs by a mucous or mucopurulent secretion. Owing to 

tion. thickening of the nasal mucous membrane there is partial or 

total obstruction to nasal breathing, giving rise to interference 

obstruSton^ with suckliug, dyspuca, and even acute attacks of asphyxia. 

The latter are prone to occur especially in the newly born w^ho 

are not accustomed to breathe through the mouth and "swallow" 

the tongue. 

Every case of acute rhinitis associated with severe local 
^^tlSi^^or (membranous deposit) and systemic (vomiting, rapid loss of 
diphtheria, strength) syniptoms should arouse the suspicion of being diph- 
theritic or scarlatinal in character. 

Acute rhinitis is not rarely complicated by otitis, laryngitis 
and bronchitis. The prognosis is generally good, although in 
young infants convalescence is slow. 

Treatment. — Avoidance of exposure to all atmospheric 
changes. Cleansing of the nostrils by repeated instillation of a 
few drops of a 2 per cent, solution of bicarbonate of soda, alter- 
nated with lukewarm mentholated olive oil or albolene. Careful 
feeding, if necessary, by the spoon. As measures of temporary 
rehef, we may recommend local apphcations of atropine (% per 
cent.), cocaine (1 per cent.), or suprarenal solutions (Yio per 
cent.) and camphor and the salicylates and quinine internally. 



DISEASES. OF NOSE, THROAT AND EAR. 237 

More or less strict isolation of the patient. Attention to con- 
stitutional symptoms. Serum therapy whenever it is indicated 
(diphtheria.) 

I^ Natrii salicyl gr. xij | 0.8 

Puh\ camphorse gr. iij | 0.2 

Chocolate q. s. | 

M. ft. puW. no. vj. 

Sig. : One powder every two hours for a child 3 years old. 

RHINITIS CHRONICA 
(Nasal Catarrh, Ozena). 

It is characterized by marked congestion and thickening of 
the nasal mucous membrane and hypersecretion — hypertrophic Hypertrophic 
rhinitis, or by atrophy of the various layers of the mucous mem- 
brane and foul-smelling incrustation — atrophic rhinitis, ozena. Atrophic. 
The latter form is rarely observed in children under ten years 
of age. 

Chronic rhinitis is usually the result of repeated attacks of 
acute coryza or other affections of the nasopharynx associated 
with nasal hypersecretion and obstruction to free nasal breath- 
ing (adenoids). In the presence of foreign bodies in the nose syphilitic. 
it is usually unilateral. In the nursling it is often due to 
hereditary syphilis (syphilitic rhinitis). 

Treatment. — As all forms of chronic rhinitis by respiratory 
interference and secondary glandular infection give rise to more 
or less impairment of the constitution, the treatment of this 
condition should embrace local as well as general therapeutic 
measures. The nose and nasopharynx should be kept clean by cleanliness, 
antiseptic and oily sprays and the congestion allayed by painting 
the mucous membrane twice a week with silver nitrate (1 per 
cent.), tannin-Hycerin (5 per cent, to 10 per cent.), etc. Exces- 

^' ^-^ -^ .,,. . Cauteriza- 

sive hypertrophy should be reduced by trichloracetic acid and tion. 
similar caustics and, if these fail, by means of the galvanocautery 
or nasal scissors. 

R. Thymolis gr. ij | 0.15 

Olei eucalypti gtt. v | 

Albolene q. s. ad 8i j | 60. 

M. Sig. : Nose-spray, to be used morning and evening. 

EPISTAXIS 
(Hemorrhage from the Nose, Nosebleed). 

Bleeding from the nose may be due, primarily, to trauma- 
tism, external irritation of the mucous membrane from various 



238 DISEASES OF RESPIRATORY SYSTEM. 

Numerous causes, foreira bodies, etc. ; or may occur as a result of vascular 

causes. :> o ? ' j 

excitement during the course of febrile, circulatory (especially 
after exertion) and pulmonary diseases; hemorrhagic affections, 
etc. 

Treatment. — The treatment of epistaxis varies, of course, 
with the cause. In slight hemorrhage simple compression of the 
alse nasi against the septum acts efficiently. 

In cases of moderate bleeding, sitting posture, head erect, 
with hands folded over the head, and ice application to the nose 
and nape of neck, or instillation of cold water (with some 
Astringents, yincgar, alum or potassium permanganate) into the nose will 
usually suffice. If this fails, the nares should be packed as far 
back as possible with pledgets of cotton or gauze, dipped in a 
strong solution of alum, in peroxid of hydrogen, or suprarenal 
gland solution. In secondary epistaxis due to vascular congestion 
Sedatives. ^ small dosc of morphine hypodermically in conjunction with 
the aforementioned measures will often act very promptly. As 
the last resort we turn to the post-nasal tampon which, as a rule, 
checks the hemorrhage unless hemophilia is the underlying con- 
dition of the bleeding, when the treatment must be directed 
chiefly against this affection {^q.v?). 
cauteriza- Detection of the local cause is very essential. Every visible 

tion of .... 

bleeding bleeding spot should be cauterized with chromic or nitric 
acid or with the galvanocautery. Constitutional symptoms, if 
present, should receive prompt attention. 



TUMORS AND FOREIGN BODIES IN THE NOSE. 

Mouth-breathing, snoring, and nasal speech are not due solely 
to adenoid vegetations or large tonsils. Not infrequently obstruc- 
tion to breathing is the result of the presence of mucous polypi 
(soft, jelly-like), fibrosarcomas (hard and pedunculated) or 
^bodies^ foreign bodies. The latter are usually beans, pebbles, cherry- 
stones, and so-called rhinoliths. Sooner or later they give rise to 
{^unilateral') foul, bloody discharges and implicate the lacrimal 
duct and Eustachian canal, and form a reflex cause of persistent, 
irritable cough, and asthmatic conditions. The diagnosis can 
readily be made by inspection. 

Treatment. — Tumors should be removed with the cold 
snare, galvanocautery, or by torsion with a slender forceps. 
Bleeding may be arrested in the manner outlined under Epistaxis. 



Polypi. 



DISEASES OF NOSE, THROAT AND EAR. 239 

Foreign bodies if anteriorly situated can readily be removed 
by air inflation through the free side,, or by means of a pointed ^^^^j^^^ 
forceps. If impacted farther back, it is preferable to dislodge 
the foreign body with a slender hook or forceps under cocaine 
and either extract it anteriorly or force it posteriorly into the 
nasopharynx. 

PHARYNGITIS ACUTA. 

Acute pharyngitis is rarely primary (streptococcic infection) 
but quite frequently secondary in nature as a complication of and™^^^ 
acute rhinitis, tonsillitis, acute exanthematous affections, etc. ^^^°^ ^^^' 
Primary pharyngitis is ordinarily of short duration and mani- 
fested by dryness in the pharynx, pain in swallowing, and 
moderate rise of temperature. The pharynx is reddened, some- 
what swollen, and often granular. 

Secondary pharyngitis will be considered in connection with 
the diseases it comphcates. 

Treatment. — Attention to the bow^els, rest in bed, Priessnitz symptomatic 
compresses to the neck and antiseptic sprays to the throat. 
Liquid non-irritating diet. 



PHARYNGITIS CHRONICA. 

It may develop after repeated attacks of acute pharyngitis 
or as a result of extension of an inflammation from the adjacent 
structures. The posterior pharyngeal wall not rarely presents 
a deeply congested granular appearance, and here and there 
covered by a tenacious mucous deposit. 

The affection is associated with more or less dryness in the 
throat, hawking and coughing. On examination the fauces ap- Hypertrophy 
pear swollen and relaxed, the tonsils hypertrophied, and the 
esophageal opening covered by a thick, grayish-white deposit. 

Treatment. — Avoidance and removal of causes. Locally 
the parts *must be kept clean by mild antiseptic sprays (Dobell's 
solution), and the swelling reduced by nitrate of silver (2 per 
cent.), or tannin-glycerin (5 per cent.) solutions. Change of 
air, iodid of iron, cod-liver oil, etc., are very helpful to effect a 
cure. 



of fauces 
and tonsils. 



Nitrate of 

silver. 



I^ Suprarenal solution (1:2000), 

Dobell's solution aa Bj | 30 

M. Sig. : Throat-spray in acute or chronic pharyngitis. 



Bacterial 
origin. 



240 DISEASES OF RESPIRATORY SYSTEM. 

ANGINA 
(Sore Throat). 

Tonsillitis Acuta, Amygdalitis, Quinsy. 

Children under two years of age seem to present a decided 
immunity against tonsillitis. On the other hand, all forms of 
angina are extremely common in children over two years old. 
Those with a ''catarrhal habit" are especially prone to contract 
the disease. Streptococci, staphylococci and pneumococci, among 
other micro-organisms, form the most frequent primary cause, 
and are productive of the usual symptom-complex which is 
characteristic of similar contagious and infectious diseases of 
Chills, childhood. Thus, the attack is ushered in suddenly wath a chill, 
pain and Hsc of temperature (with evening exacerbations), vomiting (in 
swe mg. yQ^j^ggj- children) and sometimes convulsions. The younger 
the child the less conspicuous the dysphagia. Hence the impor- 
tance of a routine examination of the throat in all febrile affec- 
tions. 

To avoid unnecessary repetition it is advantageous to classify 
tonsillitis in accordance with the tonsillar deposit as follows : — 

Angina Catarrhalis. — Redness and swelling of one or both 
faucial tonsils and adjacent tissues. Thin mucous 

Mucous •> 

exudation. cxudation. 

Angina Follicularis. — The deposit begins as one or more 
White dots. whitc. Small pellicles upon the middle or anterior por- 

tion of the tonsil. The white dots, at first distinctly 
isolated, soon coalesce to form yellowish- or greenish- 
white elevated patches. These are removable without 
profuse bleeding, and reform slowly. 
Angina Parenchymatosa (Quinsy, Peritonsillar Abscess). 
— The tonsil (usually one) and peritonsillar tissue are 
greatly enlarged, often displacing the uvula. It is bluish 
Abscess in color and dousrhy in consistency. The deposit, at 

"point." ^ -^ . .\ . .. 

first white, gradually turns yellowish-green, resemblmg 
the "point" of an abscess. Pus on puncture. 

Angina Herpetiformis. — The deposit begins with minute 
Vesicles. vcsiclcs, which tend to burst and leave behind superficial 

ulcers. This form of amygdalitis usually involves both 
tonsils and is at times complicated by stomatitis. 

Angina Gangraenosa (Necrotica). — The tonsils are mod- 
erately enlarged and almost completely covered by a 



DISEASES OF NOSE, THROAT AND EAR. 241 

greenish-yellow, continuous, deposit surrounded by a red 
zone. The exudation if removed leaves behind a deeply 
seated ulcer. The deposit often spreads from one tonsil depSt. 
to the other by way of the anterior pillars, palatine arch 
and uvula. 
Angina Ulcerosa (Vincentii). — It greatly resembles the 
latter but is usually limited to one tonsil, and occasionally 
presents a pseudomembrane. Vincent's bacillus in pure Vincent's 
culture is almost always found in the exudation. 
The course of the different varieties of tonsillitis varies but 
slightly. After subsidence of the acute initial symptoms pre- 
viously spoken of, the disease assumes a much milder aspect, 
except as to prostration, pain in swallowing and evening exacer- 
bations of the fever. The latter ranges between 102° and 105° 
F. and is especially high in follicular tonsillitis. More or less 
marked lymphadenitis is present in all forms of angina, and in 
accord with the tonsillar involvement it is either unilateral or Torticollis. 
bilateral. Parenchymatous angina is not infrequently associated 
with pseudo-torticollis, and pain on moving the jaws is present 
also in the other forms of the affection. 

In uncomplicated cases recovery is the rule in from three to 
ten days but quite a number of deviations from the usual course 
are observed. Tonsillitis is not rarely the forerunner of true 
diphtheria or rheumatic affections with their respective complica- Rheumatism, 
tions, and cases are on record where it proved to be the source of 
general septic or pyemic infection. 

Differential Diagnosis. — Angina may be confounded vi^ith 
influenza, glandular fever, diphtheria and scarlatina. In iiiflii- jy^^^^^^^^^^. 
enza the exudation is slie^ht and not stricth^ limited to the tonsils : \^°^ ^^°°^ 

o J ' influenza, 

adenitis is comparatively rare. Furthermore, influenza is charac- fianduiar 

^ -^ ' tever and 

terized by the simultaneous presence of respiratory, digestive, diphtheria, 
and often nervous phenomena, while in tonsillitis throat symp- 
toms predominate. Glandular fever differs from tonsillitis by 
the comparative absence of tonsillar manifestations and prepon- 
derance of glandular swelling (also of the bronchial, esophageal 
and retroperitoneal glands). The distinction between severe 
cases of tonsillitis and moderately severe forms of diphtheria 
without a bacteriological examination is often very difficult in 
the first twenty-four hours of the disease. In pharyngeal 
diphtheria the pseudomembrane appears as a small uneven, 
grayish white, slightly elevated patch upon the inner tonsillar or 

16 



242 DISEASES OF RESPIRATORY SYSTEM. 

faucial surfaces of the throat. The deposit augments by rapid 
spreading, within a few hours reaching the posterior wall of the 
pharynx and adjacent structures. The surrounding, uncovered 
areas are grayish in color, due to overcrowding of leucocyte- 
nuclei and mucus beneath. The tonsils are moderately large in 
size, but the submaxillary glands are large and hard, assuming 
the shape of a large walnut and bulge conspicuously forward. 
The deposit, if removed, leaves a raw, bleeding surface and 
rapidly reaccumulates. This clinical picture differs materially 
from that of tonsillitis and often proves useful in arriving at a 
Differentia- corrcct diagnosis. Tonsillitis with and even without erythema 
scarlatina, may be mistaken for scarlatina and a differential diagnosis is 
sometimes impossible until a few days after beginning of the 
attack. 

Treatment. — In view of the possible serious complications 
tonsillitis should be arrested at its inception. The following 
mixture should be used every two hours as a local application — 
undiluted, by means of a cotton swab in young children, or 

Antiseptic , -^ , . , / 

gargle, diluted 1 to 20 of water, as a gargle, m older ones : — 

R. Acidi carbolici 3ss | 2. 

Pulveris camphorse gr. x | 0.6 

Alcoholis 3ij I 8. 

Glycerini q. s. ad 5.i j | 60. 

M. Sig. : One teaspoonful in twenty of water as a gargle every two 
hours, etc. 

For the relief of pain cold Priessnitz's compresses or an ice 
Salicylates. Collar to the neck and salicylates internally. The latter is in- 
tended also to guard against rheumatic affections. In angina 
parenchymatosa if suppuration is inevitable it should be hastened 
of pus. by hot applications and the abscess opened early. Irrigation of 
the throat. Rest in bed, liquid diet, plenty of water. Avoidance 
of transmission of the disease. (See also ''Diphtheria," page 
296.) 

HYPERTROPHY OF THE TONSILS. 

Chronic enlargement of the tonsils often develops after re- 
peated attacks of angina or pharyngitis, not rarely follows scar- 
secondary. latina or diphtheria and is frequently associated with adenoids. 
When the tonsils become so large as to obstruct respiration, the 
same symptom-complex makes its gradual appearance as is path- 
ognomonic of adenoids. As in the latter anomaly, removal of the 
hypertrophied tissue is the only actual cure, and unless con- 



DISEASES OF XOSE, THROAT AND EAR. 243 

traindicated by hemorrhas'ic diathesis, should be undertaken Danger of 

^ ^ nemorrhage. 

with the aid of a tonsillotome — the earHer the better, since the 
presence of more or less degenerated tumors acts not only as a 
cause of a number of reflex phenomena (e.g., enuresis), but as 
a harboring place for divers pathogenic bacteria, including the 
tubercle bacillus. 

Tonsillotomy is usually performed in the following manner : — 
The patient is placed on a table (if an anesthetic is to be Tonsillotomy, 
used) or seated on the lap of an assistant or nurse. The arms are 
immovably fixed by means of a wide towel or sheet. The ton- 
sillotome is introduced into the mouth like a tongue depressor 
and turned sideways and pressed against the base of the hyper- 
trophied tonsil so that its summit protrudes through the circular 



Arrest of 



Fig. 65. — Tonsillotome. 

Opening of the tonsillotome. With the tonsillotome thus fixed 
and the thumb of the operator in the handle of the blade the 
latter is firmly driven through the gland. 

The same procedures are repeated for the other tonsil. 

Slight bleeding calls for no treatment. Profuse hemorrhage 
should be promptly checked by local use of ice-water, peroxid ^^^^^o^^^^se. 
of hydrogen, adrenalin (1 : 1000), local pressure, or other thera- 
peutic measures generally employed in local hemorrhage. 

ADENOID VEGETATIONS 

(Hypertrophy of the Nasopharyngeal or Luschka's Tonsil). 

The mucous membrane of the rhinopharynx is normally rich 
in lymphoid or adenoid tissue which bears the name of naso- 
pharyngeal or Luschka's tonsil. Like the faucial tonsils the 
latter is subject to frequent attacks of inflammation with second- 
ary hypertrophy. \Mienever the hypertrophied adenoid tissue 
assumes such proportions as to more or less fill the nasopharyn- 
geal space and obstruct nasal breathing, a pathognomonic clinical 



244 



DISEASES OF RESPIRATORY SYSTEM. 



syndrome develops which, though apparently insignificant in its 
lesion, is often very serious in its immediate and remote 
consequences. 

The clinical picture unfolds gradually, almost insidiously, 
growing more pronounced from time to time as the patient 
"catches cold." The child is unable to clear the nasopharynx, 
and the retained irritating nasal discharge helps to swell the 
adenoid tissue and to obstruct the rhinopharynx. The child is 
Open thus forced to breathe through the mouth. As immediate results 
we find that it keeps the mouth open, sleeps restlessly with the 




Fig. 66. — Adenoids. Note typical idiotic face. (Skeffield.) 



Snoring. 



Apathy. 



mouth open and as a rule snores heavily. He is frequently 
awakened by extreme dryness of the throat, and a croupy, 
harassing cough. In the morning he is tired, complains of head- 
ache, is drowsy and apathetic. His speech is dull, nasal (m and 
stuttering, n souud like b and d) and hesitating, and sometimes stuttering. ^ 
Were it possible to bring these little sufferers under proper 
treatment at this stage of the disease, quick and uneventful re- 
covery would be the rule. Unfortunately, however, the laity, 
nay, the physicians as well, rarely think these symptoms of 
sufficient gravity to necessitate medical and particularly surgical 
intervention. The deplorable condition is therefore allowed to 



1 It should be remembered, however, that the presence of adenoids 
does not necessarily produce the typical symptoms of the disease. It all 
depends upon the proportionate size of the tumor to that of the rhino- 
pharynx. 



DISEASES OF NOSE, THROAT AND EAR. 



245 



proceed and the tumor to spread and sprout. The sequelae ap- 
pear in rapid succession. The labored breathing sooner or later br^e^aTmng. 
produces deformity of the thorax (pigeon breast) and often 
curvature of the spine. Owing to non-participation of the 
nose in respiration there is gradual atrophy of the levators alae J^/tSo™ax^ 
nasi et labii superiores, the depressors alse nasi, and the septum 




Fig. 67. — Adenoids. Note funnel-shaped chest. {Sheffield.) 



mobile. The nose becomes pinched and pointed, the external 

angle of the eye deeper than the internal, the lower lip droops, 

the lower jaw sinks down, and the face assumes that dull, fixed appearance 

and irresolute expression which is so characteristic of adenoids. 

In addition to this, hearing is impaired as a result of secondary 

catarrhal inflammation of the Eustachian tube, etc. The child 

is absent-minded and dull of perception, does poorly at school, 

and becomes the target for abuse and corporal punishment by 



Idiotic 



Mental 
backward- 
ness. 



246 



DISEASES OF RESPIRATORY SYSTEM. 



teachers and parents — all for no fault of his. When brought to 
the physician — often chiefly on account of impaired hearing — the 
diagnosis can readily be made by mere inspection. Such a super- 
ficial examination, however, should not be relied on, as similar 
symptoms are produced by nasal obstruction from other causes 
(deformities, growths, foreign bodies, etc.). Inspection of the 




Fig. 68. — Adenoids. Note spinal curvature. {Sheffield.) 



Deformity 
of palate. 



Mass in 
rhino- 
pharynx. 



mouth reveals the bony palate high and narrow, leaving insuffi- 
cient space for the teeth and causing their displacement. The 
faucial tonsils are greatly enlarged (in about 25 per cent, of the 
cases), the posterior pharyngeal wall is granular, and, with the 
velum palati raised, often shows the distal ends of the adenoid 
vegetations. Rhinoscopy confirms the presence in the naso- 
pharyngeal space of a pale-red, smooth, soft tumor which some- 
times resembles a mass of earthworms. It bleeds readily. The 



DISEASES OF NOSE, THROAT AND EAR. 247 

diagnosis is further corroborated by palpating with the finger the 
soft masses blocking the rhinopharynx, or by nipping oft a small 
portion of the adenoid vegetations by means of an adenoid forceps 
introduced behind the velum palati. 

The diagnosis once established the treatment should be prompt 
and energetic. Mild cases in their early stages may be arrested 
at their inception by scrupulous cleanliness of the nasopharynx, cleanliness. 
local applications of Lugol's solution or 2 per cent, of nitrate of 
silver, change of air, outdoor exercise, cold shower baths, and 
hematinics and alteratives internally. These procedures should 
also be followed in cases with hemorrhagic diathesis where an 
operation is contraindicated for fear of uncontrollable bleeding, he^morrhage. 
and in those associated with other grave aiTections. In all other 
cases removal of the adenoids is the onlv actual cure, and should 




Fig. 69. — Adenoid Curette. 

be undertaken as early as possible. The mode of procedure varies 
with each individual case. In young children under three years 
of age the operation may be performed without an anesthetic, in 
sitting posture; in older ones or in those who are hypersensitive 
to pain and shock preferably under primary anesthesia with ether 
(drop by drop method), ethyl ether or nitrous oxid gas, in 
recumbent posture. The child's arms are fastened to the sides 
of the thorax by a wide towel, and his jaws are separated by a 
mouth-gag placed between the left upper and lower teeth. The 
operator stands on the right side of the patient and introduces 
the adenoid curette sideways into the latter's mouth and passes it 
beneath the soft palate and up along the anterior wall until he 
reaches the vault of the rhinopharynx. The physician then 
implants the cutting edge of the instrument into the adenoid mass 
and makes a firm semicircular movement, directed backward, 
downward and forward. One such movement usually suffices to 
remove the tumor. It may be followed up, however, by a few 
lighter, similar strokes, to smoothen the rough edges. The patient 
is then turned on the side to allow the blood to drain into a basin. 
This may be facilitated by the injection of ice-cold water through 
the nostrils. After arresting the more or less profuse hemor- 



Careful 
anesthesia. 



248 



DISEASES OF RESPIRATORY SYSTEM. 



Bandage 
over mouth. 



Tonics 



rhage, which always accompanies the operation, the child is put 
to bed for a few hours until he has regained full consciousness 
and kept indoors for a day or two on a non-irritating, cool, liquid 
diet. 

After-treatment. — To prevent the recurrence of the adenoids, 
which is prone to take place in children with a tendency toward 
glandular hyperplasia, it is advantageous to instill into each nostril 
a few drops of Lugol's solution, once every other day for a period 
Local of about four weeks, and to use an oily antiseptic spray for several 
weeks thereafter. This procedure will prevent also adhesions 
between the cut surfaces and the soft palate. Delicate children 
should be put on syrup of the iodid of iron, cod-liver oil, etc. 
To regulate nasal breathing it is often necessary by means of a 
bandage to keep the mouth closed, especially at night, and to take 
prolonged breathing exercises with closed mouth. Impaired 
speech sometimes calls for instruction in speaking or, in the event 
of a paretic condition of the velum palati arising from inactivity, 
for treatment by electricity or tonics. In the majority of in- 
stances, however, the operation is followed by immediate restitutio 
ad integrum. All reflex symptoms and to a great extent even the 
deformities of the thorax subside rapidly. 



Anesthetic. 

Sepsis. 
Hemorrhage. 



DANGERS AND ACCIDENTS ATTENDING 
ADENOID OPERATION. 

Simple and harmless as the operation is under ordinary condi- 
tions, it is not always free from danger. As in more serious 
operations the possibility of fatality from the effect of the anes- 
thetic or infection is gravely to be borne in mind and the fre- 
quency of primary or secondary — occasionally fatal — hemorrhage 
should engage the constant attention of the operator. 

To obviate untoward complications all such preparations 
should be made as are customary with capital operative work. 
Ethyl chlorid and ether (drop by drop method) should be the 
anesthetic of choice, and primary in preference to deep anes- 
thesia. The instruments to be used should be carefully sterilized, 
and the field of operation and everything coming in contact with 
it rendered as aseptic as possible. Before beginning the operation 
the surgeon should test the efficiency and entirety of his instru- 
ments, and see to it that he is amply supplied with all such drugs 
(peroxid of hydrogen, suprarenal gland in solution 1 .TOOO, the 
tincture of chlorid of iron, etc.) and implements (post-nasal 



DISEASES OF NOSE, THROAT AND EAR. 



249 



tampon, artery forceps, sponge holder and stypic gauze — which 
can be used to exert direct pressure upon the bleeding spot; actual 
cautery, etc.), as will enable him to promptly check profuse 



hemorrhage. 



RETROPHARYNGEAL ABSCESS 
(Retropharyngeal Lymphadenitis). 

Retropharyngeal abscess is a disease of early infancy when 
the retropharyngeal lymph-nodes are in a state of highest develop- 



Styptics. 




Fig. 70. — Retropharyngeal Abscess. Note characteristic attitude 
of head — 'Tseudotorticollis." (Sheffield.) 

ment. It usually begins as retropharyngeal lymphadenitis, most Lymph- 
frequently the result of infection by offensive nasopharyngeal ^^^^^^^^s- 
discharges. More rarely it is due to spondylitis of the cervical 
vertebrae or occurs as a metastatic abscess or in consequence of 
trauma. Not all cases of lymphadenitis undergo suppuration ; on 
the contrary, quite many retrogress and escape attention. Hence 
the apparent rarity of retropharyngeal disease. Some cases 
undergo suppuration and break spontaneously, and others run a 
rather latent course, and when seen by the physician present fully 
developed abscesses. Digital examination of the throat usually 



Dysphagia. 



250 DISEASES OF RESPIRATORY SYSTEM. 

reveals a round or oval fluctuating mass the size of a pigeon's 
egg, in the median Hne of the pharynx, and more rarely laterally 
on a line with the velum palati or somewhat below it. In the 
advanced stage the abscess may be recognized as a bluish-red 
tumor on ordinary inspection of the pharynx. 

The symptoms vary with the size of the tumor. In marked 
cases they consist of dysphagia, snoring respiration, especially 
Snoring, during sleep, muffled voice and, with progressive growth of the 
swelling, dyspnea and attacks of asphyxia. Where deglutition is 
very painful there is also sympathetic /'^£'MJc»-torticollis. Occa- 
sionally the submaxillary, parotid and other neighboring glands 
are involved, and in spontaneous rupture of the abscess metas- 
tatic abscesses are apt to develop in the supraclavicular fossa, 
mediastinum, and lungs. 

Treatment. — Early opening of the abscess is therefore 
imperative. This is best accomplished by gently perforating it 

Evacuation , - . , , . . , . , , 

of pus. by means oi a pomted artery clamp and widenmg the puncture by 
opening the clamp. As soon as the perforation is made the child's 
head should be promptly bent forward to prevent the pus from 
entering the larynx (danger of asphyxia, aspiration pneumonia, 
etc.) and the nose and throat cleared of blood, pus and mucus. 

In multiple communicating abscesses with palpable involve- 
ment of the adjacent glands, the operation is preferably per- 
formed (with a knife) from the outside so as to afford thorough 
drainage. 

Relief from the symptoms is very prompt after evacuation 
of the pus. Rapid recovery, however, occurs only in primary 
streptococcic or staphylococcic abscesses ; in metastatic and tuber- 
culous abscesses the disease proceeds a protracted course, the 
prognosis depending upon the original disease and the age and 
vitality of the patient. 

OTITIS MEDIA. 

The gravest feature of nasopharyngeal affections, be they 
primary or secondary, is their great tendency to ear complica- 
^^'to^'lfa^so^ tions. The nasopharynx and ear being in direct communication 
through the Eustachian tube, infectious material can readily 
travel from the nose and throat to the middle ear and transfer the 
disease from one locality to the other. Hence the frequency of 
ear disease in rhinitis, adenoids, divers exanthematous affec- 
tions, influenza, etc. Only a small percentage of cases of otitis 



DISEASES OF NOSE, THROAT AND EAR. 251 

media are contracted through traumatism or extension of an Traumatism, 
inflammation from the external auditory meatus, and, in infants, 
middle-ear disease with masked symptoms is occasionally observed ,,^^ ,, 
in connection with wasting diseases {e.g., tuberculosis, marasmus, catarrh, 
syphilis). 

The infection may remain limited to the Eustachian tube 
(catarrh of the Eustachian canal), and give rise to very few and 
mild symptoms. The child may complain of earache for a day Earache. 
or two, perhaps, wake up at night with a crying spell, but get 
immediate and usually permanent relief after application of heat 
or some "ear drops." Sometimes the pain may return and get 
much more intense, and examination of the drum would show 

Injection of 

injection of the drum or, perhaps, a slight mucopurulent dis- drum, 
charge indicating spontaneous rupture of the membrane. The 
discharge may continue for a few days or weeks and disappear 
without further ado. In another group of cases, due to greater 
virulence of the infective material or possibly neglect, the inflam- 
matory process pursues a more violent course (otitis media piiru- i t a- 
lenta). The temperature rises, the earache is very intense, the charge, 
child is very restless, cries almost incessantly, rubs or strikes 
the ear with its hands, and as the symptoms persist there may be 
vomiting and cerebral irritation up to convulsions. If the pus 
is not evacuated, we soon find that it eats its way into the deeper 
structures, leading either to an acute or chronic involvement of 
the bone (mastoiditis). In severe infections this stage of the Mastoiditis, 
disease is often reached within a few days. The aforementioned 
constitutional symptoms are greatly exaggerated. The local 
signs, in addition to intense earache, deafness, headache and 
marked congestion of the drum, also are augmented by tenderness 

• 1 11 11- r 1 • • Marked 

over the mastoid process and by swellmg of the tissues covering swelling. 
the bone, extending downward along the entire side of the neck 

. Constitutional 

and forward to the retromaxillary fossa, pushing the auricle for- symptoms, 
ward. The upper and posterior walls of the meatus are more or 
less swollen and the drum is highly inflamed, bulging and irregular 
in contour. The further course of the affection depends greatly 
upon the mode of treatment. If the inflammatory process is 
allowed to continue the pus may find its way either externally, 
somewhere along the side of the neck, into the throat (retro- 
pharyngeal abscess) or, in malignant cases, into the lateral sinus 

. . . . . Involvement 

(phlebitis, thrombosis), or the middle fossa of the skull (menin- of sinus; 

.... ... meninges. 

gitis, purulent encephalitis). The same grave condition is some- 



252 DISEASES OF RESPIRATORY SYSTEM. 

times observed in otitis pursuing a very slow course — months or 
years. In these cases it is usually found that the patient is suffer- 
cerebrai i^g from recurrent attacks of earache with or without profuse 
purulent discharge, more or less severe headache, dizziness, 
occasional rise of temperature, tenderness over the mastoid proc- 
ess, and, toward the end, loss of weight, anorexia, persistent 
headache and repeated vomiting. 

The disease having reached this deplorable stage one is very 
rarely apt to err in the diagnosis. A question may arise as to 

Differentia- whether the meningeal symptoms are secondary to otitis or to 
"centrar' somc Other affection {e.g., pneumonia, sepsis), or primary in 

pneumonia. (^\^2,r2iCiQr . A history of ear disease and the presence of local ear 
symptoms (discharge; inflammation of the drum, etc.) at once 
point to its true nature. Neither is there any difficulty in diag- 
nosing otitis media purulenta with acute symptoms. The diag- 
nosis, however, is not so easy in cases with an insidious course. 
It is especially difficult when the ear symptoms are masked by 
manifestations of the primary affection (e.g., influenza), but an 
otoscopic examination almost invariably clears up the diagnosis, 
and should always be resorted to whenever inexplicable pain or 
temperature prevails. Only very recently I had occasion to find 
double otitis in a boy 14 months old who, for three weeks, was 
treated by a prominent clinician for ''central pneumonia." Mild 
cases of middle ear disease may be mistaken for otitis externa. 
In this affection, however, the local signs are limited to the 
external auditory canal (redness and narrowing of the meatus 

Differentia- . , . , ■" ^ , . n ^. ., , . , ,, .. 

tion from without mvolvcment of the drum). Similarly middle ear disease 
ear may be confounded with furunculosis or foreign bodies in the 
auditory meatus, but these can readily be eliminated by an 
otoscopic examination showing the seat of the lesion. Occasion- 
ally an abscess in the external canal burrowing itself through the 
cartilaginous portion of the canal in back of the ear may be 
mistaken for mastoid abscess ; in such cases constitutional symp- 
toms and inflammation of the drum are absent and the abscess is 
superficial and communicating with the swelling in the external 
canal. 

Bearing in mind the great tendency of nasopharyngeal affec- 
tions to lead to ear disease, and the latter to become a source of 
everlasting misery and death, it is self-evident that all precautions 
should be taken to prevent the causes and their dreadful results. 
During the course of acute febrile, especially exanthematous dis- 



DISEASES OF NOSE, THROAT AND EAR. 258 

eases, the nasopharynx should receive especial attention in the 
way of careful, gentle cleansing. Warm salt water or albolene 
should be instilled into the nose twice daily, preferably with a 
spoon or dropper, lest forcible syringing may drive the discharge nasopharynx, 
from the nasopharynx into the Eustachian tube. Hypertrophied 
tonsils and adenoids should be removed and chronic nasopharyn- J(£SomJ. "^ 
geal catarrh treated with appropriate remedies. The instillations 
should also be continued after the appearance of ear symptoms, 
and as long as the membrane is intact syringing of the ear with 
warm boracic acid solution will prove beneficial. If the otitis 
continues and the drum does not rupture spontaneously, free 
paracentesis should be performed without delay, to allow the paracentesis. 
pus to escape. The mode of after-treatment is still subject to 
controversy, several prominent otologists preferring the ''dry" m^^t. ^^^^^' 
method (drying of the external auditory canal several times a 
day and loosely packing with absorbent gauze) to repeated 
syringing. Where the discharge continues instillation of a few 
drops of a 2 per cent, solution of nitrate of silver, or in very 
chronic cases cauterization of the tympanum with trichloracetic 
acid will be found to act splendidly. If sensitiveness over the 
mastoid is detected and the constitutional symptoms show that 
disease is rapidly growing worse, an attempt should be made to 
arrest its progress by a new paracentesis, icebags and leeches and, 
if improvement does not set in early, there is nothing else left 
but immediately to proceed with opening of the mastoid process 
with a chisel to prevent the pus invading the sinus, meninges or 
brain substance. In the majority of instances a radical mastoid opVaUon. 
operation is a life-saving procedure. Unfortunately this opera- 
tion is not rarely undertaken either too late or on a patient in a 
state of very low vitality from the baleful effects of the primary 
disease, so that the results are not always very gratifying. It is 
questionable whether operative interference is to be advised after 
the disease has spread to the meninges or brain. The recoveries 
in these cases are certainly very few and far between. 

LARYNGITIS ACUTA. 

Catarrhal Laryngitis; Spasmodic or False Croup; Laryngitis 

Stridula; Membranous, Non-diphtheritic Croup. 

Acute primary, idiopathic laryngitis is comparatively rare in 
children, except as the result of the traumatic action of strong 
gases, vapors, fluids or excessive heat. On the other hand, laryn- 



Icebag. 



254 DISEASES OF RESPIRATORY SYSTEM. 

gitis quite frequently occurs in conjunction with divers acute 
exanthematous diseases, especially measles and influenza, often 
ary. f^jj^^g attacks of rhinitis, pharyngitis, tonsillitis and esophagi- 
tis, and may develop in connection with intra- and extra-laryngeal 
growths. This so-called secondary laryngitis affects children 
principally of from two to ten years of age. 

The severity of the symptoms is often by far out of propor- 
tion to that of the underlying anatomic lesion. Thus, simple 
hyperemia of only a small portion of the laryngeal mucous mem- 
brane not rarely gives rise to marked symptoms of suffocation. 

Several forms of laryngitis are noted in practice : — 

1. Catarrhal Laryngitis. — The child complains of sore 
throat and sensitiveness of the larynx to pressure. The cous^h is 

Barking j r o 

cough, dry, short, and barking; the voice husky or only slightly muffled. 
Respiration is normal; fever is absent or slight. Expectoration 
is at first slight and of a mucous nature, later more profuse and 
mucopurulent. The attack lasts about a week. 

Occasionally, especially in neglected cases or in those suffering 
from affections of the nasopharynx, the laryngitis may pursue 
a chronic course with a tendency to permanent alteration of the 
voice. In this event laryngoscopic examination usually reveals 
a moderate hyperemia of the laryngeal mucous membrane, and 
in some cases slight erosions. 

2. Spasmodic Laryngitis (Laryngitis Stridula, False 
Croup). — It develops, either very suddenly or after a few days' 

Sudden iH^i^ss, with Catarrhal laryngitis or nasopharyngitis. Sudden 
of^croup^ attacks usually occur in children under eight years of age, more 
frequently boys than girls. After retiring apparently healthy 
and sleeping fairly well until about midnight (this may also 
happen during the day after prolonged sleep, when the naso- 
pharyngeal or laryngeal secretion desiccates and gives rise to 
irritation of the larynx, and possibly edema of the subchordal 
tissue) the child wakes up with a harsh, croupy cough, inter- 
rupted by deep inspiratory stridor. The child looks frightened 
and anxiously gasps for air, its face is flushed and bathed in 

Intense pcrspiratiou, its eyes stare and its lips are cyanosed, and the 
dyspnea, ^j^^j^ cHuical picture is very alarming. The dyspnea usually 
passes off in a few minutes but may last hours with slight remis- 
sions and gradual improvement. Ordinarily the child is well 
again in the morning except for a simple mild laryngitis which 
may subside in two to ten days or give rise to renewals of the 



DISEASES OF NOSE, THROAT AND EAR. 



255 



Ascending. 



attack for a few successive nights. Sometimes the paroxysm 
may be so severe as to require intubation or tracheotomy for 
immediate rehef. Spasmodic croup occasionally forms the 
beginning of pertussis, measles, influenza or membranous, non- 
diphtheritic croup. 

3. Membranous, Non-diphtheritic Laryngitis. — In the begin- 
ning the symptoms are those of simple laryngitis. Very soon, 
however, the catarrh is increased in intensity. The cough 
becomes harsher and more croupy, the voice hoarse (sometimes 
aphonia), inspiration prolonged and expiration noisy. It may 
begin also with bronchial catarrh and become suddenly compli- 
cated by fibrinous tracheolaryngitis — ascending croup — reach a 
very high degree of intensity, become more severe from hour to 
hour, and threaten suffocation, if not immediately relieved by 
intubation or tracheotomy. The aspect is still worse when the 
croupous inflammation descends into the bronchi — bronchial Descending. 
croup. In this condition the patient may cough up white reticu- 
lated shreds (which float in water) or complete cylinders with 
dichotomic ramifications or multiple dendritic branchings. The 
prognosis in such cases is very grave. The pulse fails, the 
dyspnea and cyanosis increase, the patients fall into a state of 
sopor and die from collapse. Not infrequently fatal brain symp- 
toms occur as a result of passive venous congestion in the brain 
and transudation in the ventricles. The course and termination 
of the disease, however, is not always so bad, and quite a number 
of uncomplicated (sometimes complicated by bronchopneumonia) 
cases recover without much ado. 

This non-diphtheritic form of laryngitis is often mistaken for 
diphtheritic membranous laryngitis, but a diagnosis can in the 
majority of cases be made with the aid of the following differ- 
ential points : — 



Dyspnea, 
cyanosis, 
eventually 
asphyxia. 



Differential 
diagnosis. 



Membranous Diphtheritic 
Laryngitis. 

Diphtheria bacilli present. 

Distinctly contagious, giving also 
a history of contagion. 

Early enlargement of the submax- 
illary glands. 

Diphtheritic patches are found, as 
a rule, on the fauces and poste- 
rior pharyngeal wall. 

Albuminuria usually present. 

Treatment. — Mild cases do 
peutic measures such as rest in bed, hot baths, hot drinks (tea, 



Membranous Non-diphtheritic 
Laryngitis. 
Absent. 
Not contagious. 

Submaxillary glands, as a rule, 

not involved. 
The fauces may be covered with 

a mucous exudation, which can 

easily be wiped off. 
Absent. 

nicely on very simple thera- 



256 DISEASES OF RESPIRATORY SYSTEM. 

lemonade, milk and seltzer), Priessnitz's compresses or turpen- 
tine and camphorated oil to the neck and a few doses of sodium 
a icy a es. ^^{[^yi^^^ internally to relieve the sore throat and to stimulate 
diaphoresis. 

Should there be any tendency for desiccation of the laryngeal 

secretion, softening of the same should be endeavored by means 

Inhalations, of cxpectorants, steam inhalations and emetics. In the majority 

of instances this mode of treatment prevents the occurrence of 

attacks of spasmodic laryngitis. 

I^ Vini ipecacuanhse 3ss. [ 2.00 

Syr. scillse comp. 3j. j 4.00 

Sedatives. Syr. senega 3ij, | 8.00 

Codeinae sulph gr. ss. j 0.03 

Mist, glycyrrhizse comp q. s. ad f^ij. [60.00 

M. Sig. : One teaspoonful every two to four hours for a child 3 years 
old. 

U Eucalyptol 3j. | 4.00 

Tinct. benzoini comp Bij. [60.00 

M. Sig. : One teaspoonful in a pint of hot water for inhalation. 

Sudden paroxysms of false croup are best remedied by 
Emetics. Prompt cmesis, a hot mustard bath (see page 106), a hypoder- 
matic injection of morphine and atropine, counterirritation by a 
strong sinapism and, if the cyanosis increases notwithstanding, 
intubation or tracheotomy. 

The management of membranous non-diphtheritic croup is 
frequently quite a difficult proposition. Hence, the importance 
of its prevention by early attention to catarrhal laryngitis. 
Steam inhalation (see above) and emesis are useful remedies, 
and inhalation of amyl nitrite or chloroform is often effective 
Antispas- to relieve threatening dyspnea. Severe cases call for early 
Intubation! iutubatiou or tracheotomy. Recurrent laryngeal spasm some- 
times yields to spraying of the larynx with 2 per cent. sol. 
Antitoxin, of cocaine. As diphtheria antitoxin carefully administered is a 
safe remedy, it is always advisable to resort to it, although bac- 
teriologic examination of the pseudomembrane fails to reveal the 
diphtheria bacillus. 

Prophylaxis. — Removal of local causes, such as adenoids 
and large tonsils; change of air; tonics, especially cod-liver oil. 

LARYNGITIS CHRONICA. 

Chronic laryngitis may follow repeated attacks of acute 
catarrhal or diphtheritic laryngitis or develop slowly by extension 



DISEASES OF NOSE, THROAT AND EAR. 



257 



of inflammation from the neighboring structures. Overexertion 
of the voice and excessive smoking in boys are occasionally 
causes. 

Laryngoscopic examination shows hyperemia and swelling of inflammatory 
the mucous membrane of the larynx which vary in extent with ^^™^ '^^^' 
the duration of the affection. The mucous membrane is some- 
times covered with granulations and in severe cases shows more 
or less superficial ulceration. There is a moderate secretion of 
mucus and pus which has a tendency to desiccate, and gives the Resembles 
sensation of a foreign body in the throat. The cough is usually tuberculous 
insignificant, occasionally, however, troublesome, harsh and bark- 
ing, especially at night. 

Diagnosis. — Although syphilis and tuberculosis of the 
throat are comparatively rare in children, their presence should 
always be suspected and looked for in obstinate laryngitis. The 
following differential points are helpful in the diagnosis : — 



Lesion 



Simple Laryn- 
gitis 



Syphilitic 



Secondary 



Hyperemia, slig-ht Mottled hypere- 



thickening, ero- mia, superficial 
sion of mucous ulceration 
membrane, rare- 
ly slight ulcera- 
tion 
Expectoration. Free from tubercle Spirochetes 

bacilli 
Degflutition . . . ; Usually painless Normal 

Cough I Dry or moist, pain- 1 Slight hacking 

i less 



Tuberculous 



Tertiary 



Respiration 



Voice 



Normal 
Variable 



I Unaltered 
! 
Hoarse, nasal 



Complications. Nasopharynx; gen- Syphilitic lesions 
j eral health unaf- elsewhere 
fected 



Deep, angry Anemia, grayish 
ulcers, [ color, solid thick- 
cicatrices, j ening, worm- 
stenosis i eaten ulcers 



The same Bacilli present 



Difficult 
Infrequent 

Embarrassed 
with stenosis 
Raucous, 
husky 
The same 



Very painful 
Severe, as a rule 

Early acceleration 

Partial or complete 

aphonia 
Involvement of 
I lungs, emacia- 
I tion 



Treatment. — Attention to existing causes, especially ade- 
noids and enlarged tonsils if present; local application, three 
times a week, of nitrate of silver (1 per cent, to 2 per cent.), 
glycerate of tannin (10 per cent.), or chlorid of zinc (2 per cent, 
to 4 per cent.) ; steam inhalations (see page 256) ; cleansing of 
the nose and throat, three times a day, with Dobell's solution, and 
the like, will very promptly effect a cure, provided the laryngeal 
affection is not based on some grave constitutional affection, or 
benign (papilloma) or malignant growths. Rest to the voice is 
of material benefit. In very protracted cases change of air and 

17 



Nitrate of 
silver. 



Removal of 
growths. 



258 



DISEASES OF RESPIRATORY SYSTEM. 



constitutional treatment. Faradization of the larynx is often 
very serviceable to relieve aphonia. 



I^ Codeinse sulph gr, ss 

Creosoti carbon 3ss 

Syr. acacias q. s. ad f 5i j 



0.03 
2. 
60. 



M. Sig. : One teaspoonful every three hours for a child 6 years old. 



Passive or 
secondary. 



Pathologic 



CEDEMA GLOTTIDIS. 

Edema of the larynx occurs in two forms: Active (inflamma- 
tory, phlegmonous), and passive (serous). Inflammatory edema 
Active, may be primary, usually traumatic {e.g., scalds or burns), or 
secondary, as a result of extension of inflammation from neigh- 
boring structures. Passive edema is usually observed in connec- 
tion with grave kidney and heart diseases — often long before 
dropsy is manifested in any other part of the body — and second- 
arily to pressure on the larynx by swellings or growths. 

Anatomically edema of the larynx consists of a yellowish- 
white or reddish tumefaction — a serous, seropurulent or san- 
guinolent transudation into the submucosa — involving the upper 
findings, portions of the larynx, the epiglottis, the aryepiglottic folds, the 
false (rarely the true) vocal cords, and the mucous membrane of 
the arytenoid cartilages. 

These local changes can readily be detected by inspection of 
the larynx, often without the mirror, by simply depressing the 
tongue and puUing it forward, and by digital examination. 

The result of such swelling of the laryngeal tissues is quite 
obvious, namely, interference with normal respiration. The 
dyspnea is at first paroxysmal, and, if the edema is not very 
marked, only moderately severe. The poor little patient hacks 
and coughs, in vain trying to clear the throat. If the edema 
advances, the dyspnea becomes extreme; symptoms of asphyxia 
set in which, if not promptly reHeved, lead to a fatal issue. 

(Edema glottidis should not be mistaken for spasmodic croup ! 

Treatment. — Partial edema may be reduced by icebags to 
the neck, swallowing of ice, local application of suprarenal 
extract solution (1 :1000) and morphine and pilocarpine hypo- 
dermatically. In severe cases tracheotomy should be resorted 
to in addition to the mode of treatment just outlined. Recur- 
rence of an attack should be prevented by prompt attention 
to the etiologic factors. 



Dyspnea. 



Sedatives. 



Tracheotomy 



DISEASES OF LUNGS AND PLEURA. 259 

LARYNGEAL TUMORS. 

Neoplasms of the larynx are very rarely seen in children. 
This is especially true of malignant growths. Papillomata are Papiiiomata. 
not quite so rare, and are sometimes congenital. Their usual 
seat is at the true vocal cords, and if of considerable size they 
give rise to obstinate, severe cough, hoarseness, dyspnea and at- 
tacks of asphyxia. These symptoms develop however, gradually, 
and sometimes disappear spontaneously owing to retrograde 
metamorphosis of the tumor. Recurrences are frequent. Laryn- Differentia- 
geal neoplasms may be confounded with adenoids, retropharyngeal adSioTdJ^ 
abscess and croup, but the diagnosis can readily be made by gei7abscess^ 
laryngoscopic examination. Operative treatment should be ^^^ croup. 
instituted only in cases presenting troublesome symptoms. 
Endolaryngeal removal of the growth is the procedure of choice. 
Tracheotomy, in threatening asphyxia. 

FOREIGN BODIES IN THE LARYNX. 

Various articles of food, little playthings, buttons, needles, 
ascarides, etc., may find their way into the larynx. Small foreign 
bodies are usually expelled by the attacks of forcible coughing. 
Larger non-impacted articles may be removed by an extubator 
or similar forceps after cocainizing the upper part of the larynx. 
Foreign bodies firmly impacted in the larynx should be removed 
under anesthesia through the tracheotomy incision. In threaten- 
ing asphyxia tracheotomy should be performed immediately ^i^^hreaten-^ 
irrespective of subsequent procedures. To reduce hyperemia, ^^^ asphyxia. 
ice externally and internally. Local antiphlogosis (Lugol's solu- 
tion, 1 per cent, nitrate of silver) after removal of the foreign 
body. Anodynes for the relief of pain and irritability. (For 
removal of ascarides see page 226.) 



DISEASES OF THE LUNGS AND PLEURA. 

BRONCHITIS AND BRONCHOPNEUMONIA. 

Tracheobronchitis; Capillary Bronchitis; Lobular Pneumonia. 

Bronchopneumonia in children is usually secondary in nature 
(forming a complication of divers acute and chronic diseases) 
and is generally preceded by or associated with a catarrhal inflam- 
mation of the mucous membrane of the trachea and bronchi. As 
the tracheobronchitis advances the inflammation spreads to the 



260 DISEASES OF RESPIRATORY SYSTEM. 

line bronchioles — capillary bronchitis — and, finally, to the pul- 
irreguiar monary alveoli — lobular- or broncho-pneumonia. In the latter 
^of^iesicm! affcctiou the consolidation is irregularly distributed, sometimes 
over the entire lung, in variously sized patches. On section the 
affected lobules present quite a smooth surface of bluish-red 
color, and contain a mucosanguinolent fluid. When placed in 
water they sink to the bottom. In cases of long standing atelec- 
tasis, emphysema and caseation are common complications. 
°cougtu In tracheitis the cough is short, dry and harsh, becoming longer 
and softer as the inflammation extends to the bronchi. Respira- 
tion is but little embarrassed, the temperature is normal or slightly 
elevated and the general health corresponds with the underlying 
condition. The onset of bronchitis, on the other hand, is signal- 
ized by a rise of temperature of from two to three degrees, some- 
times vomiting and marked restlessness. The cough is frequent 
and painful, breathing is accelerated and somewhat difficult, and 
auscultation reveals a great number of large, harsh and moist 
rales and sibilant rhonchi which are transmitted over the entire 
Wheezing, chcst wall and give rise to the characteristic wheezing and whis- 
tling which are readily heard at some distance from the patient 
and felt by the palpating hand. This "rattling of the chest" 
usually diminishes in intensity or disappears temporarily after 
forcible coughing. 

Under suitable treatment the tendency of primary tracheo- 
bronchitis is toward gradual evanescence. After a few days the 
disease assumes a milder course ; the cough becomes looser and 
less frequent; the breathing slower and less noisy; the general 
condition rapidly improves, and recovery is often complete within 
from seven to fourteen days. 

Not infrequently, especially in secondary bronchitis, where 
Often ^^^ primary etiologic factors remain active, or in neglected cases, 
chronic ^]^g catarrh pursues a protracted course (chronic tracheobronchi- 
tis) ; aggravation of the condition alternates with amelioration; 
the child continues to hack or cough for weeks or months, 
presents large and moist rales over different portions of the 
chest, but may otherwise remain free from any constitutional 
symptoms. In a small number of cases chronic bronchitis forms 
tubercui?sis° ^ prccursor of tubcrculosis of the bronchial glands or lungs. 

In young and delicate children tracheobronchitis is always 
fraught with the danger of terminating into capillary bronchitis 
or bronchopneumonia. Indeed transition of the inflammation 



DISEASES OF LUXGS AND PLEURA. 



261 



from the large bronchi to the line bronchioles (bronchiolitis, 
capillary bronchitis) and the lung tissue (bronchopneumonia or 
lobular pneumonia) not rarely proceeds insidiously, and may 
exist for some time, especially in the lower lobes, before being 
detected. 

As a rule, extension of the pulmonary inflammatory process 
is associated with sudden rise of temperature (up to 105° F.) 
with its concomitant symptoms, and increased frequency of respi- 
ration. The cough becomes dry, short and very painful. The 
nostrils dilate and contract. The eyes are dull. The face is 
pale, cyanotic, and often covered with perspiration. No mathe- 
matical distinguishing line can be drawn between the symptoms 
and physical signs of capillary bronchitis and catarrhal pneu- 
monia, except, perhaps, that in capillary bronchitis the pulmonary 
lesions are more diffuse (the whole bronchial tree may suddenly 
become involved) while in lobular pneumonia more local. As 
the disease advances the local pneumonic foci gradually multiply, 
become larger and more confluent, and coalesce in extensive 
masses. Then, and often not until then, can dullness be demon- 
strated on percussion. Where the patch is small the percussion 
note may be normal or even tympanitic. Inspection discloses 
retraction of the lower ribs during breathing. Auscultation 
elicits accentuation of the expiratory sound, bronchial breathing, 
bronchophony over the dull portions and fine crepitation, in addi- 
tion to large, soft and sonorous rales, distributed over dift'erent 
parts of the lungs, especially over both sides of the spine, and 
along the axillary lines. 

Lobular pneumonia being usually a secondary affection (pri- 
mary pneumococcic bronchopneumonia may, like lobar pneumonia, 
end by crisis) runs a very protracted course, from two to six 
weeks or longer. This is often due to repeated extension of the 
inflammatory process, sometimes wnth disappearance of the 
original focus. This accounts also for the apparent improvement 
and relapse. Under the circumstances the wear and tear upon 
the child's constitution is very great, especially since with per- 
sistent anorexia tissue repair is at complete abeyance. 

The heart's action grows weaker; the power to cough dimin- 
ishes, notwithstanding exaggeration of the physical signs ; breath- 
ing becomes more diflicult, and the pulmonary circulation more 
and more obstructed. The child finally succumbs to autoinfection 
and cardiac exhaustion (the overdistended right heart being 



Transition 
into capillary- 
bronchitis or 
bronchopneu- 
monia. 



Rise of 
temperature. 



Rapid 
breathing. 



Confluence 
of lesions. 



Dullness. 



Bronchial 
breathing. 



Dyspnea. 



Heart 
weakness. 



262 DISEASES OF RESPIRATORY SYSTEM. 

unable to propel its content), not rarely preceded by attacks of 
suffocation, coma, and convulsions. 

The prognosis is not always so grave. In some cases, espe- 
Grave cially in children whose constitution has not previously been 
prognosis, undermined by wasting diseases, defervescence occurs after a 
week or so, the dullness diminishes, the cough loosens, sleep 
becomes more restful, respiration less painful, the appetite 
returns, and if not interrupted by complications, gradual recovery 
ensues within a few weeks. 

On the other hand, fatal termination after a few days' sickness 
is not at all rare. This is more apt to occur in primary, pneumo- 
coccic bronchopneumonia from an overwhelming toxic effect 
upon the heart muscle and the cerebrum (meningitis, enceph- 
aHtis). 

Pyothorax, miliary tuberculosis, gastroenteritis, stomatitis, 
more rarely otitis, pleuritis, and gangrene of the lungs, form the 
compiica- principal complications. Empyema, tuberculosis and pulmonary 
gangrene are usually found only in cases of bronchopneumonia 
with delayed resolution, as a result of caseation and liquefaction 
of the unabsorbed inflammatory products. 

Treatment. — The management of bronchopneumonia in 

young children depends upon the underlying condition of the 

disease. Primary, pneumococcic, lobular involvement, like lobar 

pneumonia, usually proceeds a self-limited course and is little 

influenced by therapeutic measures. On the other hand, second- 
spreads by . 
continuity, ary Catarrhal pneumonia spreads by continuity and may often be 

arrested in its inception by early and energetic treatment. This 
is true particularly of bronchopneumonia supervening tracheo- 
bronchitis — as already alluded to, in the beginning, a simple local 
catarrh, readily amenable to prompt attention. 

As the initial symptoms of bronchitis and bronchopneumonia 
Ener etic ^^^ ^^^ always easily distinguishable, and as the success of our 
treatment, treatment invariably depends upon its promptitude, it is good 
practice to err in the direction of judicious overtreatment rather 
than in that of irresolute undertreatment, and to at once proceed 
with active therapeutic measures in tracheobronchitis and bron- 
chopneumonia alike. 

The treatment consists of induction of free perspiration, 
enhancement of expectoration, allaying nerve irritability and 
pain, and maintenance of the patient's strength. Seeing the 
patient in the early stage of the disease we direct the administra- 



DISEASES OF LUNGS AND PLEURA. 



263 



tion of a hot mustard bath of about three minutes' duration and ^^th^^^^^^*^ 
the apphcation of a pouUice consisting of the following ingre- 
dients : Five parts each of flaxseed-meal and camphorated oil, 
one to two parts of mustard, and a sufficient quantity of boiling 
water to make a thick paste by thorough stirring. This mass is ^°^^^ ^^^^• 
spread on thin gauze or paper (two layers) and applied snugly 
to the chest and back. The child is then wrapped in an oiled- 
silk jacket, lined with absorbent cotton, and in a blanket, which, 
with the hyperpyrexia of the body, maintains the heat of the 
poultices, so that renewal is required but three or four times in 
twenty-four hours. This poultice has special advantages over 
any other in use. As just mentioned, it requires but occasional 
changing, thus saving time and labor and avoiding unnecessary 
exposure of and annoyance to the patient. The mustard and 
camphor act as mild counterirritants, and after some time bring 
the blood to the surface, thus relieving the pulmonary engorge- 
ment. Furthermore, the skin over the chest and back does not 
become "soggy and sodden," or ''water-logged" from the use of 
this poultice as is apt to occur from prolonged application of 
ordinary flaxseed poultices. 

In conjunction with the external treatment the patient receives 
also a few doses of sweet spirits of niter and liquor ammonium Diuresis and 
acetate which act very kindly both as diaphoretics and stimulants. 

The beneficial results derived from this mode of treatment 
are manifest within a few hours. The suffering infant who but 
a short time before had been on the verge of collapse — moaning, 
tossing and twitching from pain and distress, gasping and panting 
for a free breath of air — now lies peacefully enjoying calm 
repose and healthful sleep, ready and apparently able to battle 
for a new lease of life. The system having been greatly relieved 
of its toxemia by means of the free perspiration, the disease now 
usually assumes a much milder course. Indeed, it is not at all 
uncommon to see a severe attack of tracheobronchitis to end then 
and there, and that of bronchopneumonia to resolve itself into 
simple bronchitis. 

The enthusiasm just expressed applies, of course, only to 
such cases as are ordinarily met as a result of a "cold." This 
treatment is surely no panacea for respiratory embarrassment 
complicating grave affections of other bodily organs, e.g., heart 
or kidney. Here symptomatic medication is in order — at best an 
unthankful task. 



Effects of 
treatment. 



264 



DISEASES OF RESPIRATORY SYSTEM. 



To enhance free expectoration we resort to the following 
expectorant mixture : — 



R. Ammonii carbon gr. xvj 

Vini ipecacuanhse 3ss 

Syr. scillse comp 3j 

Syr. senegse 3j 

Syr. Tolutani 3iv 

Aquas destil q. s. ad Bij 



M. Sig. 
years old. 



One teaspoon ful every two or four hours for a child two 



Anodynes. 



Expec- 
torants. 



To this we may add a small quantity of the camphorated 
tincture of opium (gtt. 2 to 5) or codeine sulphate (gr. Yqq) for the 
relief of pain and to allay nerve irritation. For the latter pur- 
pose an ice-bag to the head or sodium bromid internally often 
does well. 

We cannot pass this question without expressing our disap- 
proval of the absurd criticism often heard as to the use of 
expectorants. When a little infant is tormented almost to death 
by an incessant, dry, hacking cough and the painful phenomena 
associated with it, it is no empiricism to administer an expecto- 
rant mixture which helps nature to rid the lungs of effete 
material (which more or less obstructs respiration and causes 
autoinfection by systemic absorption) and permits the patient to 
refresh upon a brief period of rest and sleep. 

The maintenance of the child's strength is most essential to 
the successful management of bronchopneumonia. The heart 
should be looked after from the very inception of the disease, 
stimulants. For be it remembered that death in pneumonia is due to heart 
failure and not to pulmonary insufficiency. In the early stages 
of the disease we rely principally upon strychnin (gr. %oo to 
y^o), but as the circulatory and respiratory difficulties increase 
we do not hesitate to administer camphor (gtt. x of a 15 per 
cent, sterilized camphorated oil) hypodermatically and digitalis 
and strophanthus by mouth, as indications demand. 

Every effort should be made to replenish the vital body fluids 
consumed during the active febrile process by suitable nourish- 
ment such as water, milk, beef -tea, broths, fruit-juice, etc. (See 
also ''Pneumonia.") 

When called upon to treat a case of bronchopneumonia of 
several days' or weeks' duration that has failed to respond to 
active treatment, our efforts should be directed toward the pre- 
vention of pyothorax or tuberculous infiltration of the lungs. 



Camphor. 



DISEASES OF LUNGS AND PLEURA. 



265 



Fresh air. 



lodids. 



A great deal can be accomplished by an ample supply of fresh 
air, the iodids, creosote and essential oils by mouth and inhala- 
tion. (See also "Chronic Pneumonia.") 

Whenever possible, the child should be removed to the country 
(seashore or mountains), and, weather permitting, kept outdoors 
most of the time. 

The iodids will be found very useful to hasten resolution 
(preferably in the form of sodium iodid gr. ^, t. i. d. for a child 
one year old). We usually recommend its administration from 
the sixth day of the disease until resolution has been established, 
and then continue with the syrup of the iodid of iron and the 
syrup hypophosphite compound, which act both as an efficient 
alterative and tonic. 

Creosote is indicated in all stages of the disease. It should creosote. 
be prescribed in small doses several times a day. The tent made 
of bed-sheets hung around the bed and moistened with creosote, 
oil of eucalyptus and the like is of service, especially in tracheo- 
bronchitis. 



LOBAR PNEUMONIA. 
Croupous or Fibrinous Pneumonia, Pneumonitis. 

Acute lobar pneumonia is an acute, specific, inflammatory 
affection of the lung tissue arising as a result of invasion by the 
encapsulated diplococcus of Fraenkel-Weichselbaum. It may 
occur as an independent process or in connection with other dis- 
eases, e.g., influenza, measles, diphtheria, scarlet or typhoid fever, 
etc. It is communicable and occurs occasionally in epidemic 
form. 

Genuine pneumonia in children, as in adults, is characterized 
by three pathologic stages : Engorgement, red hepatization or 
consolidation, and gray hepatization, followed by resolution or 
purulent infiltration. The pleura is almost invariably implicated. 

Primary lobar pneumonia usually ushers in suddenly, often 
after exposure to cold or wet, with a chill, vomiting, high tempera- 
ture, and more or less marked dyspnea. The initial symptoms 
are frequently misleading. They may consist of vomiting, 
diarrhea, pain in the abdomen, nosebleed, and prostration, sug- 
gesting the beginning of typhoid, or convulsions and vomiting 
may predominate justifying the diagnosis of meningitis. Where 
the pneumonic lesion is located centrally {central pneumonia), 
the physical signs, nay, even the cough, may be absent or slight, 

17a 



Three 
stages. 



Sudden 
onset. 



Chill. 



Absence of 
cough in 
central 
pneumonia. 



266 DISEASES OF RESPIRATORY SYSTEM. 

so that remittent fever is often thought of or even intermittent 
fever, if the temperature pursues an irregular course. Further- 
more, there are also numerous abortive cases of pneumonia which 
terminate in a few days — often before the diagnosis has been 
estabhshed. 

Of course, the majority of cases of pneumonia present typical 
physical signs and can be readily disclosed on careful examina- 
tion. Auscultation reveals during the first and third stages fine 
crepitation. Crepitation at the edge of the consolidation, and during the 




Tubular 



Fig. 71. — Diplococciis Pneumoniae (Pneumococcus) : (a) 
single diplococci ; (b) the same in chains (Wolf's double stain). 
Leitz ocular I, oil immersion y±2. {Lenhartz and Brooks.) 



second stage, distinct tubular breathing and bronchophony over 
breathing, the affected portion of the lung. In the first day or two of the 
disease the percussion sound is usually tympanitic, but as the 
Dullness, pneumonia advances, first dullness and later flatness can readily 
be elicited, the experienced hand perceiving also a distinct increase 
of sense of resistance on percussion. Pectoral fremitus is ordi- 
narily not sufficiently distinct in young children except when they 
cry aloud, which act should always be encouraged to facilitate the 
detection of the physical signs. 

Croupous pneumonia runs a self-limited course, between five 
and thirteen days, or longer, most frequently terminating by 
crisis, at a time when the disease is at its height. Until then, 
in the absence of unexpected complications, there is little change 



Self-limited. 



DISEASES OF LUXGS AXD PLEURA, 



26; 



in the clinical picture of the affection. The fever remains high 
(104° to 105° F.), with slight morning remissions; the pulse- and 
respiration-ratio is greatly disturbed, from 1 to 3.5 to 1 to 2; the 
urine scanty, high colored, rich in salts (with diminution in 
chlorides) and occasionally in pepton and aceton ; the cough is 
short, dry and painful; older children (rarely those under three 
years of age) expectorate rusty sputum; the face is flushed, the 
tip of the nose and lips are cyanotic; the tongue is coated, pasty. 



Continued 
hyper- 
pyrexia. 



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Fig. 12. — Fever Curve of Typical Lobar Pneumonia in a child 15 
months old, ending by crisis. (Sheffield.) 



its tip red ; the child is restless, sleepless, and tosses from side to 
side. As the crisis approaches and the circulation becomes more 
disturbed, the expiratory moan becomes louder and shorter, the 
cough more harassing, the breathing more superficial, the thirst 
more intense; the child lies helplessly (often rigid), usually on the 
affected side, in a state of apathy and exhaustion or in delirium. 
The change wrought by the establishment of the crisis is marvel- 
ous. Almost in an instant the heart's action calms down (the 
pulse is often irregular and very feeble) ; the breathing becomes 
slower, deeper; the tubular breathing-sounds are successively 
supplanted by crepitation, large and small soft rales, and normal 
vesicular respiration; the dullness on percussion gradually disap- 



Expiratory 
moan. 



Crisis. 



268 



DISEASES OF RESPIRATORY SYSTEM. 



Lysis. 



pears; the cough diminishes, the temperature drops to normal or 
below it; the appetite improves and convalescence proceeds unin- 
terruptedly, so that recovery is usually complete within a few 
days after the crisis. 

This favorable course is the rule. Exceptions are not rare. 
Not rarely pneumonia terminates by lysis. Defervescence may 
be tardy, the temperature reaching normal by two or three stages. 
Occasionally after a true crisis and apparently durable defer- 
vescence, recrudescence takes place ; the temperature again rises 





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Fig. 7Z. — Fever Curve of Fatal Apex Pneumonise, with marked 
Cerebral Symptoms in a child 2 years old. {Sheffield.) 



Complica- 
tions. 



and after a few days' persistence finally subsides by lysis. In 
p^e^umonfa^ some instances pneumonia runs a very protracted course; the 
inflammatory process "creeps" from lobe to lobe, and finally 
terminates in unresolved, chronic or the so-called caseous pneu- 
monia. Quite frequently the pleura is markedly implicated, 
{pleuropneumonia) , without or with an effusion into the pleura, 
in the latter event frequently resulting in pyothorax. Termina- 
tion of pneumonia in pulmonary gangrene is rare. 

Primary pneumonia under suitable management offers quite 
a favorable prognosis. More serious are the cases in which the 
lung involvement is very extensive {e.g., double pneumonia) or 
located at the apex. Still less favorable is the pneumonia super- 
vening other infectious and contagious diseases, especially if it 



DISEASES OF LUXGS AXD PLEURA. 



269 



is preceded by a prolonged exhausting siege of the underlying 
affection. Complications substantially mar the prognosis as 
regards immediate and ultimate recovery, meningitis and peri- 
carditis especially proving fatal. Acute nephritis usually ends in 
recovery. Gangrene, pyothorax, peritonitis and suppurative 
inflammation (pneumococcic metastases) of the bones and joints 
not rarely yield to early operative interference. Exceptionally 
fulminating attacks of pneumonia, with extremely high tempera- 
ture, marked dyspnea, and very rapid and feeble pulse are met 
which prove fatal within two or three days. The relation between 
high leucocytosis and a favorable prognosis is still an open 
question. 

Diagnosis. — In the initial stage lobar pneumonia may be 
confounded with lobular pneumonia, pleurisy, meningitis and 
intermittent fever. 

In the second stage, with pleurisy with effusion, and in the 
absence of cough (which often occurs when the bronchi are free), 
and the presence of abdominal pain and tympanites (the pleural 
pain is frequently erroneously referred to the abdomen; the 
tympanites is a result of intestinal fermentation, and swallowing 
of sputum and air) with peritonitis or appendicitis. Errors in 
diagnosis are prone to be made, especially in "central pneumonia" 
with masked physical signs. 

In the third stage of the disease, with miliary tuberculosis 
and typhoid fever. 

Accidental supervention of angina and erythema (the latter 
often as a result of heat or rubefacients) may lead to the suspi- 
cion of scarlatina. 

Bearing in mind the characteristic symptoms of the diseases 
for which pneumonia is apt to be mistaken, there ought to be no 
difficulty in eliminating most of them. The greatest difficulty is 
usually experienced in the differential diagnosis between acute 
lobar pneumonia and catarrhal pneumonia and acute miHary 
tuberculosis : — 



Sequelae. 



Differentia- 
tion from: 
Broncho- 
pneumonia 
and pleurisy; 



Appendicitis; 



Miliary 
tuberculosis 
and typhoid 
fever ; 



Scarlatina. 



Acute Lobar Pneumonia. 

Generally a primary disease. 
Onset sudden. 
High regular fever. 
Inflammatory process localized. 
Physical signs distinct. 
Termination by crisis the rule. 



Catarrhal Pneumonia. 
Secondary. 
Gradual. 

Moderate and irregular. 
More diffuse. 
Indistinct. 
By lysis. 



270 



DISEASES OF RESPIRATORY SYSTEM. 



Commun- 
icable. 



Fresh air. 



Pure water. 



Entero- 
clysis. 



Acute Lobar Pneumonia. 

Onset sudden and marked. 
Fever high and regular. 
Tuberculin test negative. 
Sputum contains pneumococci. 
Duration from one to two weeks 
with tendency to recovery. 



Miliary Tuberculosis. 

More gradual and masked. 
Very irregular. 
Positive. 
Tubercle bacilli. 

From three to six weeks, ending 
fatally. 



See also Pleurisy, page 278. 

Pneumonia being a communicable affection it calls for all 
such hygienic precautions as are ordinarily employed for the 
prevention of other contagious and infectious diseases. As the 
contagium is carried by means of the sputum, the latter should be 
collected in separate receptacles, preferably small pieces of gauze, 
and destroyed. 

The active treatment of pneumonia is essentially symptomatic 
— intended principally to make the patient comfortable and to 
maintain his power of resistance. 

Fresh air is the sine qua non! It purifies the respiratory 
tract, eases respiration, facilitates pulmonary circulation; hence, 
relieves and regulates the heart's action, reduces temperature, 
cheers the patient in those endless, wakeful hours, which are 
characteristic of pneumonia, and, last but not least, disinfects the 
sick-room, and thus prevents transmission of the disease to others 
and autoinfection of the patient. 

Plenty of pure drinking water is the next most important 
requisite. This heavenly beverage should be given to the little 
patients ad libitum, unless temporarily contraindicated by uncon- 
trollable vomiting, when only small quantities should be admin- 
istered. Pure water cleanses the mouth and alimentary canal, 
which in children with pneumonia is usually infected by the large 
quantities of putrid sputum swallowed ; it quenches the ever- 
present, agonizing thirst ; stimulates expectoration and aids in the 
reduction of temperature. Moreover, at a time when anorexia is 
complete, little children, like fish, seem to subsist solely on water, 
and when the body fluids, desiccated by the burning heat, are at a 
very low ebb, nature seems to find in water a grateful auxiliary, 
to ''turn the tide." 

It is very advantageous to have a standing order to employ 
daily a high intestinal irrigation to cleanse the bowels and to 
relieve the painful flatulence. Enteroclysis may be repeated a 
few times a day for the purpose of stimulating the action of the 
heart and kidneys. 



DISEASES OF LUNGS AND PLEURA. 271 

Water should serve as the only antipyretic, when reduction of 
fever is indicated. As long as the temperature is below 103° F., Hydro- 
no antipyresis is necessary. In higher temperatures, sponging, ^^^'^^p^- 
warm baths, cold packs, and, in older children, cold baths followed 
by brisk friction in accordance with the directions given under 
"Hydrotherapy," should be resorted to. 

Occasionally we are called upon to relieve pain, allay the dry 
cough, subdue the nervous irritation and to support the heart's 
action. 

Pain in pneumonia is best relieved by local heat, either in the 
form of a flaxseed and mustard poultice (see page 263) or cloths counter- 
immersed in warm mustard water and wrung out, and covered 
with oiled silk. These may be left in place for from ten to 
twenty minutes, and repeated twice or thrice a day or more often 
if the pain persists. 

The same local remedies are also efficient to lessen the har- 
assing cough. 

Excessive nerve irritability is either the result of toxemia or 
hyperpyrexia, or both. If due to high fever the treatment is self- 
evident. As warm baths combine antipyretic and soothing quali- 
ties to the nerve system, they are admirably adapted for the 
purpose. In cerebral irritation caused by the bacterial toxins an 
effort should be made to eliminate the latter by colon irrigation, 
diuresis and hot baths. In the majority of instances, however, we 
have to have recourse to the bromids, chloral and similar reme- 
dies, especially when convulsions supervene and not rarely 
threaten the life of the patient. 

Cardiac debility setting in early is a very grave proposition. ^^^ ^^^ 
Camphor and strychnine in gradually increasing doses are best gij.'^chnine 
suited for the purpose. Whenever possible, stimulation should be 
employed hypodermatically, to obviate gastric disturbances. In 
severe cases nitroglycerin and digitalis are indicated. We should 
not exhaust all stimulants at once, but always keep one stimulant 
in reserve to have something to fall back on when an urgent 
necessity arises. 

Protracted and unresolved pneumonias respond favorably to 
the iodids, which may in small doses be begun with about the io<^i<is. 
fifth day of the disease. lodism can readily be prevented by 
minute quantities of belladonna. 

The problem of feeding pneumonia patients is a very difficult 
one. It is well to bear in mind that a filled stomach by upward 



272 DISEASES OF RESPIRATORY SYSTEM. 

pressure greatly interferes with respiration and cardiac action. 
The nourishment should be very light and easily digestible, and 
Feeding, g^y^^ jj^ yg^-y Small quantities. It is remarkable how often appar- 
ently delicate infants withstand a very tedious and trying course 
of pneumonia with barely any food. Breast-fed babies when suf- 
fering from dyspnea should receive mother's milk from a spoon, 
since by overlapping the child's mouth and nose the breasts are 
very apt to cut off the little pure air supply the child is able to 
obtain. 

The mouth and nasopharynx should be cleansed twice a day. 



CHRONIC PNEUMONIA. 
Unresolved Pneumonia, Fibroid Pneumonia. 

The mode of development of chronic or unresolved pneumonia 
has already been referred to when speaking of lobar and lobular 
pneumonia (q.v.). The lymph in the lungs degenerates into 
Pathology, fibrous tissuc and caseous matter, and the pulmonary interstitial 
connective tissue undergoes hypertrophy, leading to induration 
and contraction of the parenchyma, and bronchiectasis. 

After apparent termination of the pneumonia, the child con- 
tinues to cough, fails to regain its strength, suffers from embar- 
rassed respiration, and now and then exhibits rise of tempera- 
ture. Examination of the chest reveals circumscribed areas 
(most frequently over the upper lobes) of dullness, bronchial 
breathing, bronchophony and large crepitant rales. In children 
^ ^ ■ with an undermined constitution or an hereditary tuberculous dis- 

Tendency to _ •' 

tuberculosis, position this Condition often gives rise to phthisis and early death. 
Stronger children, especially if the lesion is small, may after an 
indefinite period of suffering finally recover. 

Treatment. — Early attention to the pneumonia, in its acute 
and chronic states, is of primary importance. Removal of the 
patient from stuffy unsanitary rooms, and allowing a free influx 
of pure air will do much to prevent the destructive tendencies of 
the infected foci. With the same object in view we must avoid 
administering drugs which suppress cough — nature's method of 
clearing the lungs of impurities. Early sojourn in the mountains 
^^^- and mild seashore resorts; nutritious food; breathing exercises; 
the internal administration of small doses of creosote and guaiacol 
and large doses of the syrup of the iodid of iron with cod-liver 
oil and malt will help to enhance a cure. 



Change of 



PLEURITIS. : 

B Guaiacol carbon 3ss | 2 

Chocolate 3j 1 4 

]\I. Ft. pulv. no. XV. 

Sig. : One powder every four hours for a child 4 years old. 



PLEURITIS 

(Pleurisy). 

The pleura, like other serous membranes, may be affected, 
primarily as a result of trauma, or invasion of pathogenic bac- primary. 
teria, such as the pneumococcus, streptococcus, the microbe of 
rheumatism, etc., or secondarily by extension of an inflammation 
from neighboring structures. Primary pleurisy is comparatively 
rare in young children. The secondary variety, however, is secondary 
quite common in connection with pneumonia, tuberculosis, acute 
lieart disease, and aft'ections of the abdominal org-ans. 



Pathologically pleuritis is characterized by congestion and Pathology 
roughness of either the parietal or visceral layer of the pleura or 
of both ; a fibrinous exudation upon the pleura ; in severe cases 
a more or less large collection of (serous, serosanguinolent, or 
purulent) fluid between the surfaces of the pleura, or between 
the gaps and in the meshes of the fibrinous exudation. In accord 
with the extent and location of the pleural eft'usion, there is more 
or less severe displacement of the contiguous structures. 



I. DRY PLEURISY. 

It is quite probable that many cases of dry pleurisy in young 
children escape detection. This is apt to occur especially in 
■secondary pleurisy, where the symptoms of the original disease 
•obscure those of the complication. ^Moreover little patients often 
refer the pathognomonic "stitch pain'' to the abdomen instead of 
the side. Apart from the pain the subjective symptoms are few 
and mild. The child instinctively abstains from coughing and deep 
breathing, and, like an adult, lies on the aft'ected side. As a rule, 
the diagnosis can readily be made on hearing the pleuritic fric- 
tion sound — a dry, crackling sound on inspiration. The termina- 
tion of dry pleurisy is either in rapid and uneventful recoA'ery 
(sometimes leaving behind slight pleural thickening and adhe- 
sions) or in the graver form of the malady — i.e.. in pleurisy with 
eff'usion. 



Stitch pain. 



Coush. 



Friction 
sound. 



38 



274 DISEASES OF RESPIRATORY SYSTEM. 

II. PLEURISY WITH EFFUSION. 

A perceptible pleural effusion, be it composed of serum, blood 
and serum, pus or chyle may generally be recognized by the 
following distinctive features : — 

Inspection. — Dyspnea with impairment of movement of the 
affected side. 
Bulging. In large effusions bulging of the affected area of the thoracic 

wall, and not rarely prominence of the hypochondrium of 
the corresponding side. Occasionally enlargement of the sub- 
cutaneous veins, and superficial edema. In cases of long standing 
in which the effusion undergoes partial or complete absorption, 
Scoliosis, there is a lateral curvature of the spine with compensatory 
enlargement of the unaffected side of the chest. 

Palpation. — As compared with the healthy side, there is dis- 
tention of the intercostal spaces on inspiration, and diminution 

Diminislied . ^ .... 

vocal of vocal fremitus. In large serous effusion fluctuation may be 

fremitus. . . Z. . 

perceived by placing one nnger of one hand m the intercostal 
space, and with the finger of the other hand imparting quick but 
gentle impulses to the fluid, in the direction of the other finger. 

Auscultation. — Varying with the amount of pleuritic effu- 
sion or thickeninsf, the respiratory sounds may be diminished or 

Diminished o^ r j j 

respiratory abscut ovcr the affcctcd side and exaggerated over the healthy 

sounds. '^^ ■' 

portions of the lung. Where the effusion is small and the larger 
bronchi remain open for the respiratory current of air, we may 
hear distant bronchial breathing. In rare cases, especially in 
tuberculous pleuritic effusion, the respiratory murmur may simu- 
late cavernous breathing and lead to errors in diagnosis, especially 
if the bronchophony over the compressed lung is transmitted 
along pleuritic adhesions or the chest wall, 
^"up^to Percussion. — Dullness or flatness, corresponding to the amount 
flatness, ^f pleuritic thickening or effusion, over the affected portion of 
the lung, and often tympanitic resonance over the retracted lung 
tissue. Percussion must be performed lightly, for in the presence 
of only a thin layer of fluid forced percussion may elicit the 
normal resonance of the underlying lung. The sense of resistance 
to the finger is greatly increased. Displacement of the neigh- 
boring organs. 

Grocco's sign (paravertebral triangle of dullness) is rarely 
elicited in young children. 



PLEURITIS. 275 

With the estabHshment of the presence of a pleuritic effusion 
by means of the aforementioned physical signs, the nature of the 
pleural fluid content still remains to be determined. In the 
majority of instances this can readily be accomplished by means 
of exploratory puncture. 

Except where the exudate is buried behind a thick pleural 
membrane or, more rarely, behind tumors of the chest wall (so 
that the needle does not reach the fluid), or where the pleural 
content is too thick to pass through the needle, exploratory punc- 
ture of a pleural effusion usually reveals any of the following Different 
fluids : Serum, serum with blood, serum with pus, pure pus, or 
chyle. In accordance with this finding it is customary to dis- 
tinguish : Serous or serofibrinous pleurisy ; hemorrhagic pleurisy ; 
purulent pleurisy (empyema, pyothorax), and chylothorax. 



SEROUS OR SEROFIBRINOUS PLEURISY. 

The onset may be sudden with vomiting, chills, rise of tem- 
perature and pain in the side, or, more frequently, insidious, 
— either as a primary disease with general malaise, short cough, 
increasing dyspnea and pallor, or as a secondary affection, with 
accentuation of the symptoms of the primary disease. In 
acute pleurisies the fever may be moderately high and persist 
for from two to three weeks, and then gradually subside, even 
though the effusion remains. Bilateral pleurisy is almost always 
tuberculous. Pleurisy associated with pericardial or peritoneal Tuberculous. 
symptoms points to its tubercular character. In young children 
with a yielding thorax, absorption of large effusions is always 
associated with contraction of the affected half of the chest. The 
ribs become pressed together, the intercostal spaces narrow, the 
shoulder-blade is drawn nearer the vertebral column, and the J/t^'JJJaS' 
latter twisted (scoliosis). With complete recovery from the 
disease, the deformity may in some cases gradually disappear. 
In the majority of instances, dullness and suppressed respiratory 
murmur continue as a result of pleuritic thickening. 

The prognosis of this form of pleurisy except that due to 
tuberculosis is generally favorable. Occasionally acute pleurisy 
terminates fatally either as a result of a sudden excessive effusion 
or of pulmonary edema, embolism of the pulmonalis or of a 
cerebral vessel. 



276 DISEASES OF RESPIRATORY SYSTEM. 

HEMORRHAGIC AND TUBERCULOUS PLEURISIES. 

Protracted cases of pleurisy should always be looked upon 
with suspicion. In very many instances they are of tuberculous- 
nature. This is particularly true of bilateral pleurisy and of that 
temperature. With prolonged irregular temperature and a sero-hemorrhagic 
exudation. It is well to remember, however, that a hemorrhagic 
rhagic cfTusion is sometimes observed in scorbutic children, and that 
puncture of a blood-vessel or injury to the diaphragm or liver 
may bring forth blood in the aspirating syringe. In tuberculous 
pleurisy, before long, other symptoms of tuberculosis make their 

TubGrcl© 

bacillus, appearance. The presence of the tubercle bacillus in the exudate^ 
or, if the lungs are involved, in the sputum, and positive tuber- 
culin test settle the diagnosis. 

PURULENT PLEURISY (EMPYEMA, PYOTHORAX). 

Owing to the frequency of pneumonias (the principal cause 
of pleuritic effusions) in children, empyema is of very common 
occurrence. In the majority of instances the exudation is puru- 
lent from the beginning, more rarely it is serous at first, and, 
after a protracted course, undergoes suppurative transformation, 
as a result of an endogenous infection by the pneumococcus, 
streptococcus, staphylococcus, or the tubercle bacillus. Pyo- 
Locaiization. thorax is usually unilateral, and localized on the left side more 
frequently than on the right. Occasionally it is bilateral, e.g., 
in sepsis, pyemia, etc. Still more rarely it is multilocular, en- 
cysted, or interlobular. The amount of pus varies, from a few 
teaspoonfuls to a quart. The exudate may on the first puncture 
prove to be seropurulent, but as the disease advances the puru- 
lent character increases, becomes greenish-yellow in color, and 
sometimes fetid in odor. It may be feculent, indicating some 
connection with the abdominal contents. 

Pyothorax may develop primarily as a result of trauma. As 
Primary or ^ rulc, howcvcr, it is met secondarily to inflammatory, especially 

secondary. ' ^ -^ j ^ r j 

suppurative, processes of the thoracic and abdominal organs, of 
joints, of ribs and vertebrae, or in association with general sepsis. 
As a sequel or complication of thoracic or abdominal diseases 
empyema usually sets in very insidiously, and may remain latent 
for some time until either the effusion is so large as to cause 
bulging of the affected side of the chest, or be discovered acci- 
dentally during a routine examination for some other ailment. 



PLEURITIS. 



27 



The onset is more acute in cases due to trauma, necrosis of 
neighboring bony structures, exanthematous diseases, or in 
sudden rupture into the pleural cavity of abscesses of neighbor- 
ing organs (e.g., hepatic, perinephritic, etc.). In such cases the 
symptoms resemble those of acute serofibrinous pleurisy, except septic fever, 
that the temperature is higher and more irregular and emaciation 
and exhaustion are more pronounced. 

With early operative treatment empyema in children usually Evacuation 
terminates in recovery. If let alone, the abscess may rupture 
spontaneously either in the lungs or externally through the chest spontaneous 

11 • . AT^i ■ r 1 • rupture of 

wall — empyema necessitatis. I he pomt oi external rupture is abscess. 
usually found in the vicinity of the sternum, where the chest wall 
offers least resistance. If the rupture is in the lungs, a very large 
expectoration of pus occurs suddenly. In these cases there is 
always danger of pyopneumothorax. In another group of cases 
the pus may by inspissation lead to caseous residues and fatal 
issue from gradual exhaustion or from complications, such as 
tuberculosis, amyloid degeneration, etc. 



CHYLOUS PLEURITIS (CHYLOTHORAX). 

Genuine chylous effusion in the thorax is an exceedingly rare 
condition. ]\Iore frequently we meet with other milky effusions, 
— chyliform, latescent (non-chylous). True chylous effusion is chyiiform 
the result of injury or obstruction of the thoracic duct, allowing 
the escape of chyle either directly through an opening in the 
wall of the duct or indirectly by transudation. 

The differential diagnosis between the different varieties of 
pleurisy can readily be made by means of exploratory puncture, 
and chemic, bacteriologic, and microscopic examination of the 
fluid obtained. Bilateral (usually tuberculous) pleurisy may 
be confounded with hydrothorax. The latter condition, how- 
ever, is associated with anasarca, consecutive to heart or kidney 
disease, and generally runs an afebrile course. Left-sided 
pleurisy may be differentiated from pericarditis by the absence of 
heart-symptoms (triangular heart-dullness) in the former, and of 
lung-symptoms in the latter. The synchronous occurrence of 
both of these diseases, however, should be borne in mind. Right- 
sided, purulent pleurisy may be mistaken for an abscess or 
hydatid cyst of the liver. Careful examination will elicit the fol- 
lowing differential points : In liver aff"ections the midaxillary 
line forms the highest point of dullness, there is fluctuation, local 



Differentia- 
tion from 
Hydrotliorax; 



Pericarditis 
with effusion; 



Liver 
abscess: 



Pneumonia. 



278 DISEASES OF RESPIRATORY SYSTEM. 

tenderness and icterus; in pleurisy with effusion the last-named 
signs are absent and the midaxillary line forms the lowest point 
of dullness. Furthermore in pleurisy aspiration brings forth 
^cyst, serum, blood or pus; in hydatid cyst of the liver, a non-albumin- 
ous fluid with "booklets." 

The differentiation between lobar pneumonia and pleurisy is 
and not always easy, since both diseases often coexist. In the latter 
event, however, exploratory puncture will readily clear up the 
diagnosis. 

Pneumonia. Pleurisy. 

Dullness (late). Flatness (early). 

Temperature high. Low. 

Pulse-respiration ratio greatly dis- Not so. 

turbed. 

Bronchial breathing, bronchophony. Suppressed breathing. 

Vocal fremitus and resonance in- Diminished. 

creased. 

Treatment. — During the acute stage, keep the patient in 
bed. Limit the supply of fluids (in older children a semisolid 
Dry diet, diet, Consisting principally of cereals, concentrated soups, beef- 
juice, soft-boiled eggs, etc.). Relieve pain by salicylates, per- 
Anodynes. haps, with some opiate internally; by strapping of the chest; 
flaxseed poultices, or the following ointment : — 

I^ Tinct. iodini, 
Olei gaultherise, 
Olei terebinthinae, 
Guaiacolis, 

Ichthyolis aa 3ss | 2 

Liq. vaselini q. s, Ij | 30 

Sig. : Paint the affected parts twice a day, cover with absorbent cotton 
and bandage. 

Should the exudation increase to such an extent as to greatly 
Aspiration, interfere with breathing, aspirate and follow it up with the local 
application and strapping, and the administration of sodium iodid 
and infusion digitalis — the iodid to promote absorption of the 
fluid, the digitalis to counteract the interference with the heart's 
action by the exudate, as well as to stimulate diuresis. These 
latter procedures (except aspiration) are indicated also in cases 
running a protracted course, even without a large effusion. 
Aspiration should be practised in tuberculous pleurisy only to 
relieve the respiratory difficulty, and in chylothorax, both as a 
palliative as well as a curative measure. 

As soon as pyothorax is detected, an immediate operation for 
removal of the pus is imperative. To wait for eventual spon- 



ASTHMA. 



279 



taneous evacuation of the pus through the lungs or externally is 
hazardous, principally because of the supervening, often fatal, 
exhaustion, and of the danger of complicating pyopneumothorax, 
an incurable fistula, or caseous degeneration. In tuberculous 
empyema, surgical interference is indicated only in threatening 
suffocation, or grave cardiac embarrassment. Empyema of brief 
duration with readily flowing pus usually does well with a free 
incision into one of the intercostal spaces and good drainage. On 
the other hand, cases of long standing or those with inspissated 
pus should be treated by resection of a rib, in order to permit 
free escape of the pus. The disfigurement after such operation 
in children is comparatively slight, and many cases of regenera- 
tion of even several ribs are on record. If the empyema is 
bilateral, it is advisable to operate at separate sittings. 

Patients recovering from pleurisy, with or without effusion, 
should have plenty of outdoor air, preferably in the country, 
seashore or mountains. Older children will derive great benefit 
from horseback riding. For expansion of the retracted lung after 
a protracted attack of pleurisy with effusion, systematic breath- 
ing exercises and cold sponging of the chest or cold affusions are 
very useful. 

The importance of wholesome feeding should not be under- 
estimated. Iron, the hypophosphites, cod-liver oil, and extract of 
malt are helpful to effect the cure. 

Prompt attention to suppurative foci {e.g., necrosis of ribs or 
vertebra) and early treatment of pneumonia by fresh air will 
frequently prevent empyema. 



Dangers of 
epontaneous 
evacuation 
of pus. 



Operative 
treatment. 



Fresh air. 



Breathing 

exercises. 



ASTHMA. 

The pathogenesis of asthma in children is essentially the same 
as that in adults, — stenosis of the lumen of the bronchial tubes. 
The stenosis may be brought about either by a spasmodic con- 
traction of the muscle-fibers of the bronchioles, or by vasomotor 
turgescence and swelling of the bronchial mucosa. Children 
suffering from asthma usually present an hereditary tendency 
toward the disease, a susceptibility to protracted irritations of 
the nasopharyngeal, laryngeal, and bronchial mucous membranes, 
or a history of pertussis, bronchopneumonia or chronic bron- 
chitis. In many instances local causes, such as adenoids, deformi- 
ties of the nasopharynx, persistent thymus, etc., are met, and 



stenosis of 

bronchial 

tubes. 



280 



DISEASES OF RESPIRATORY SYSTEM. 



Hay fever. 



Night 
paroxysms. 



Rapid, 

labored 

breathing. 



Eosinophilia. 



Recurrence. 



Differentia- 
tion between 
true and 
false 
asthma. 



some cases are traceable to reflex causes, e.g., indigestion. Symp- 
tomatic asthma is occasionally based upon hay fever — resulting 
from the action of pollen of certain grasses upon the mucous 
membrane of the nasopharynx — and, finally, an asthmatic attack 
is sometimes a manifestation of hysteria. 

With these etiologic factors in view, the subdivision of 
asthma into true and false is quite justified. Clinically the two 
varieties differ in that genuine asthma is invariably associated 
with chronic bronchial catarrh, hence, is based upon a path- 
ological entity, and is of longer duration than false asthma. 
There is nothing characteristic about the catarrh. The paroxysm 
usually comes on at night. The child coughs, is a little wheezy, 
and in a few hours the typical attack is in full sway. The latter 
consists of extreme dyspnea, anxious expression of the face, 
congested eyes, cyanosis or pallor, cold extremities, restlessness 
and prostration. The patient is usually relieved by sitting up in 
bed. Auscultation of the chest reveals sonorous and sibilant 
rales, wheezing, squeaking, and whistling respiration. These 
sounds are often audible at a distance. As the attack subsides 
the breathing becomes less and less noisy, less labored, and less 
rapid. 

There may be complete apyrexia, or a rise of temperature of 
from two to three degrees. The respiratory rate may be any- 
where from 40 to 80 and the pulse 150 or over. During 
the height of the paroxysm there is marked eosinophilia, and 
where expectoration is abundant Curschman's spirals and Char- 
cot-Leyden's crystals are found in the more or less glairy mucus. 
Toward the end of an attack the thorax may appear barrel- 
shaped; but unless the asthma is chronic in nature and charac- 
terized by prolonged attacks, the emphysematous deformity of 
the chest is usually only temporary. The attack may last minutes, 
hours, or days with temporary remissions, but after abatement 
of the paroxysm the child is apparently in good health except for 
the bronchial catarrh. In genuine asthma exacerbations usually 
occur in the fall and spring, when the sudden atmospheric 
changes contribute to catarrh of the mucous membrane of the 
respiratory tract. On the other hand, paroxysms of false, 
spasmodic asthma may occur at any time when the exciting 
cause, e.g., indigestion, sudden fright, etc., presents itself. 

As a rule, asthma is not fatal per se. Delicate infants, how- 
ever, may succumb during a severe attack, as a result of suffo- 



ASTHMA. 



281 



cation, or after frequently repeated attacks, as a result of 
emphysema, cardiac dilatation, or even cerebral hemorrhage. 

The importance of curing the disease at its very inception or, 
at least, preventing or mitigating the paroxysm is obvious. A 
cure can be effected, if the cause can be found and corrected. 
Attention to abnormalities of the nose and throat is especially 
fruitful in this direction. Children having an asthmatic or 
arthritic history should be given particular care in the way of 
preventing colds and coughs, overfeeding, exposure to unhealthy 
surroundings, miasmatic affections, undue excitement, etc. An 
attack may, so to say, be aborted by early administration, pref- 
erably hypodermatically, of atropine /'2000 ^^d morphine %o oi 
a grain or occasionally by apomorphine gr. Y^q to %ooj repeated, 
if necessary, after a half an hour. The latter drug is especially 
efficient in ''dyspeptic" or "hysterical" asthma. A few drops of 
a suprarenal gland solution instilled several times a day into the 
nose sometimes act admirably. If the paroxysm continues we 
may resort to the following combination : — 



Attention to 
abnormalities 
of naso- 
pharynx. 



Morphine 
and atropine. 



I^ Natrii iodidi 3ss 

Tr. hyosciami 3j 

(Tr. quebracho 3j ) 

Ext. grindeliae rub 3ss 

Syr. pruni Virginianas q. s. ad Bij 

M. Sig. : 3j every three hours for a child 5 years old. 



A course of syrup of the iodid of iron with cod-liver oil is 
very useful in all cases, and change of cHmate, to the seashore or 
inland, is sometimes eff'ective in enhancing a permanent cure. 

In treating asthma we should always bear in mind that asthma- 
like attacks are observed as a manifestation of a large thymus, 
malaria, or heart and kidney disease, calling for specific therapeu- 
tic measures to remedy the underlying affections. 



Asthma. 

Rare in infants. 
Mostly of reflex origin. 

Cough first dry, later 

loose. 
Expectoration clumpy. 
Difficult inspiration and 

expiration, whistling. 



Spasmus Glottidis. 

Peculiar to infancy. 
Associated with rick- 
ets. 
Croupy. 

Not characteristic. 
Inspiration, stridulous. 



Duration, hours 
days. 



and Minutes. 



PuLMoxARY Edema. 

Moderately frequent. 
Secondary to cardiac 

debility. 
Short and harassing. 

Frothy, bloody. 

Inspiration and expira- 
tion. Subcrepitant, 
bubbling rales. 

Minutes. 



Change of 
climate. 



Differential 
diagnosis. 



18a 



282 DISEASES OF RESPIRATORY SYSTEM. 

EMPHYSEMA PULMONUM. 

Abnormal distention of the lungs with air occurs as a result of 
forced inspiration, e.g., in stenosis of the larynx (croup) or 
bronchioles (asthma), whooping-cough, in bronchitis or broncho- 
pneumonia with violent coughing, etc., or expiration, e.g., cornet 
playing. Owing to the great elasticity of the puerile lung and its 
tendency to rapid adjustment, emphysema is rarely observed in 
children. If it does occur, it is most frequently limited to the 
apices and the anterior borders of the lungs. Exceptionally the 
emphysema is disseminated throughout the entire lung. In this 
Exaggerated evcut the symptoms are practically the same as those in the 

resonance. . tr j 

adult, to wit : Exaggerated resonance on percussion, dyspnea, 

^ha^^ed barrel-shaped chest, and prolonged, incomplete expiration. In 

chest, cases of long standing there is consecutive involvement of the 

heart — usually dilatation of the right heart, with or without 

hypertrophy. 

The treatment consists, in addition to removal of the cause, 
chiefly of change of air (mountains), light breathing exercises. 

BRONCHIECTASIS. 

Bronchial dilatation is not very uncommon in children, but as 
it usually forms a sequel of respiratory diseases (unresolved 
pneumonia) with violent coughing, or aspiration of foreign bodies 
into a bronchus, its presence is frequently obscured by the symp- 
tomatology of the preceding affection, 
c lindricai ^^^ dilatation of the bronchus may be cylindrical or saccu- 

or sac- lated, and is almost always associated with peribronchial sclerosis 

culated. ' -^ ^ 

(pulmonary contraction), and occasionally with emphysema. 

There are no pathognomonic signs of this affection except, 

ex^ectora^ perhaps, the copious morning expectoration of greenish-yellow, 

tion of two often fetid, purulent mucus, which on standing separates into an 

upper layer of serum and a lower of pus. Auscultation of the 

affected part of the chest reveals abundant moist rales, and if the 

bronchiectatic cavities lie near the chest wall, cavernous signs, 

Free from which greatly resemble those of tuberculous cavities. In bron- 

*bacm^f chiectasis, however, the sputum is free from tubercle bacilli and 

the course is usually afebrile and often remittent — the child often 

doing well for weeks. 

Relative recoveries from this affection are on record. The 
majority of cases are incurable, and after a shorter or longer 



PNEUMOTHORAX. 



28^ 



(years) course the patients succumb to intercurrent diseases, 
such as pneumonia, miHary tuberculosis, or puhiionary gangrene. 

The treatment, therefore, is principally hygienic and prophy- 
lactic : Wholesome food, tonics, breathing exercises, inhalation of 
warm vapors with eucalyptus, creosote or turpentine ; residence in creosote 
a high, dry region. 

To facilitate emptying the dilated bronchi of their mucopuru- 
lent content, gentle inversion of the little patient a few times a 
day proves useful. 



Inversion of 
patient. 



PULMONARY GANGRENE. 

Gangrene of the lungs is not rarely a sequel of pneumonia, 
phthisis, grave exanthematous diseases, gangrenous processes of 
the mucous membrane or skin, foreign bodies in the air-passages 
(entrance of bits of food), etc. The symptomatology of this 
affection is ill defined. In older children, as in adults, the macro- 
and micro-scopic appearances of the expectoration (upper layer, 
mucopurulent ; middle, serous ; lower, almost wholly of pus ; 
remains of lung tissue and plugs containing needles of fat acids 
and detritus) are very helpful in the diagnosis. On the other 
hand, in infants chief reliance must be placed upon the general 
cachectic condition of the patient ; the coexistence of gangrene of 
the mouth, throat or vulva ; the frequent occurrence of hemoptysis 
(absence of tubercle bacilli), fetid diarrhea, and foul breath. The 
cough is usually spasmodic. 

The course of the disease is comparatively rapid, fatal ter- 
mination usually occurring within a few weeks, either from 
gradual loss of strength or from complications, such as hemopty- 
sis, pneumothorax, thrombosis, or cerebral abscess. 

The treatment is symptomatic — tonics, inhalation of antisep- 
tics, and if the gangrenous process is accessible, surgical inter- 
vention. 



Fetid 

expectoration 
of three 
layers. 



Rapid 
course. 



PNEUMOTHORAX, HEMOPNEUMOTHORAX, 
PYOPNEUMOTHORAX. 

These conditions occur principally as a result of traumatism 
(fracture of a rib or clavicle), laceration of the lungs from 
violent coughing or by foreign bodies, perforation of the lungs 
through empyema, gangrene and similar destructive processes. 

The symptomatology is the same as in adults, thus : Sudden 



Traumatic 
origin. 



284 DISEASES OF RESPIRATORY SYSTEM. 




Fig. 74. — Pneumothorax. Note compression of lungs. (Sheffield.) 



PNEUMOTHORAX. 



28.! 



severe dyspnea, bulging of the affected side, tympanitic percus- 
sion sounds. When effusion occurs, there is hyperresonance over 
the upper portion of the affected part of the chest and dulhiess or succussion 
flatness below the line of effusion. 



Succussion gives rise 



to 



sounds. 




Fig. 75. — Pneumohypodermai (five years old). The patient 
developed these symptoms suddenly during an attack of measles, 
with pneumonia. (Sheffield.) 



splashing sounds. The diagnosis can readily be corroborated by 
thoracentesis. 

The treatment consists in the administration of opiates for Aspiration. 
the pain and aspiration (of air or fluid) to relieve the intense 
dyspnea. 



1 See page 286. 



286 



DISEASES OF RESPIRATORY SYSTEM. 



Result of 

violent 

coughing. 



Crackling 

perceived 

on palpation. 



PNEUMOHYPODERMAi 
(Emphysema Cutis). 

Entrance of air into the subcutaneous areolar tissue ordi- 
narily results from rupture or laceration of pulmonary alveoli 

or bronchi during violent 
coughing or dyspnea {e.g., 
in pertussis, measles, phthi- 
sis pulmonum), or second- 
arily to suppurative or case- 
ous processes in the lungs. 
It is occasionally observed 
in connection with trauma- 
tic pneumothorax, and after 
tracheotomy and intubation. 
The air-inflation may remain 
limited to the neck or face 
or spread over the entire 
upper half of the body (see 
Fig, 75), and exceptionally 
also to the lower half. 

Pneumohypoderma can 
be detected by the distinct 
crackling sensation imparted 
to the examining finger, and 
can readily be differentiated 
from anasarca by the ab- 
sence of pitting on pressure. 
If the immediate cause 
can be promptly arrested, 
e.g., violent cough by means 
of morphine, reabsorption of 

"■^six'';;elrL^:r.'''(^,;^f/lf ) ''• the .W usuaHy occurs within 

a few weeks. Rapidly fatal 
cases, however, are on record. 




1 The new term is suggested because it indicates the exact seat of the 
trouble ; it also helps to distinguish this condition from "surgical emphy- 
sema," which is produced by gasogenic bacteria. 



CHAPTER IX. 
Communicable Diseases. 



INFLUENZA 

(The Grip). 

Influenza is an acute, communicable, epidemic and sporadic 
disease due to the influenza bacillus of Pfeiflrer and Canon. It is 




Fig. 11. — Influenza Bacilli. Sputum smear, stained with 
dilute Ziehl's solution. Bacilli chiefly intracellular, most of them 
show thickened ends. X 800. {Lenhartz and Brooks.) 

characterized by a variable group of respiratory, gastric or galt^^fc^^a^J 
nervous symptoms, marked prostration and great tendency to tur^ances" 
complications and sequelae. 

No age is exempt from this affection, and one attack neither 
predisposes nor immunizes against another one. The incubation 
period varies from two to five days ; the onset, as a rule, is sudden, 
or may be preceded by a few mild prodromata common to all 
contagious and infectious diseases. 

The attempt to classify the grip into three distinct types, to 
wit: catarrhal, gastric and nervous, is based upon an erroneous 

(287) 



288 



COMMUNICABLE DISEASES. 



Multiplicity 
of lesions. 



Cough. 



Sore throat. 
Prostration. 



conception of the pathology and cHnical data of this disease. On 
the contrary, it is the multipHcity of the lesions and symptoms 
which is characteristic of influenza. Thus, the child sneezes, 
coughs, has no appetite, vomits, complains of pain in the entire 
body, especially in the throat, head, and the lower extremities, is 
restless or lies exhausted in a semistupor for hours or days. 

The cough is dry, loud, harsh, and painful (especially over 
the region of the sternum). The throat is deep red in color, and 



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78. — Fever Curve of Atypical Influenza in a child 14 
months old. {Sheffield.) 



Gastro- 
enteritis. 



the tonsils and fauces are often covered with glairy mucus and 
occasionally with a yellowish-white, irregular deposit. In severe 
cases and especially in young children, large, soft or dry, sibilant 
rales are heard over a greater portion of the thorax, and, with 
the dyspnea and sometimes cyanosis, may readily be mistaken for 
bronchopneumonia. 

In infants particularly there are observed simultaneously 
more or less pronounced manifestations of gastroenteric involve- 
ment. The infant vomits, refuses breast or bottle, cries from 
pain of a colicky nature, and has an increased number of evacua- 
tions consisting of variously colored, undigested food. In older 
children the gastroenteric disturbance is much less marked — being 



INFLUENZA. 



289 



limited to anorexia, nausea, vague abdominal pain, and some- 
times constipation. 

The nerve symptoms range from simple paresthesia, restless- 
ness, dizziness and headache, to severe convulsions and profound 
stupor. In infants somnolence is more frequent than insomnia, 
and with the baby in a opisthotonos-like position (as a result of 
pain in the neck, trunk and 
extremities) one is fre- 
quentl}^ tempted to diagnos- 
ticate meningitis. 

Influenza begins with 
abrupt rise of temperature 
of from 3° to 5° F., which 
runs an irregular course and 
ends by lysis or crisis, often 
accompanied by free per- 
spiration, and intense pros- 
tration. 

Occasionally the tem- 
perature with its concomit- 
ant symptoms may, without 
apparent cause, continue for 
weeks (see chart, page 78) 
and likewise suddenly cease. 
This type of the disease is 
often spoken of as chronic 
influenza, and is very apt to 
be mistaken for typhoid or 
malaria. Fortunately it is 
not commonly met in chil- 
dren. The majority of cases 
terminate within from three 
to eight days. 

Convalescence is usually rapid in uncomplicated grip, especially 
in strong children and those free from hereditary or acquired 
encumbrances. In delicate and previously diseased children 
recovery may greatly be delayed by proliflc complications and 
sequelae. Pneumonias and otitides are especially common; and, 
frequently secondarily to these affections, and more rarely pri- 
marily, influenza may be complicated or followed by encephalitis, 



Paresthesia. 




Fig. 79.— Paralysis of the N. Ab- 
ducens, with convergent strabismus 
and slight facial paralysis, complicat- 
nig an acute attack of influenza. 
(Sheffield.) 



Atypical 
fever. 



Delayed 
convales- 
cence. 



19 



290 



COMMUNICABLE DISEASES. 



Complica- 
tions. 



Hemorrhagic 
processes. 



Influenza 
bacillus. 



Isolation 
of patient. 



Tendency to 
nephritis. 



Sodium 
benzoate. 



meningitis, paralysis, neuralgias, neuritis, nephritis and cardiac 
neuroses {e.g., bradycardia). 

The grip has a special predilection for hemorrhagic processes, 
such as hemorrhagic encephalitis, pleuritis or otitis, hemorrhages 
from the bowels, nose, skin, etc. — and occasionally gives rise to 
suppurative adenitis (especially of the submaxillary and parotid 
glands), rhinitis, conjunctivitis, periostitis, and more * minor 
affections. 

Every form of cutaneous eruptions may be met in this dis- 
ease, and lead to erroneous diagnoses. In the presence of simple 
erythema, for instance, influenza may greatly resemble scarla- 
tina and baffle the skill of even the keenest observer. 

In doubtful cases of grip, especially in the absence of an 
epidemic, a correct diagnosis can be arrived at only by systematic 
scientific elimination of the suspected diseases and careful search- 
ing for the influenza bacillus in the expectoration or discharges 
from the nose, throat or ear. 

Influenza is a treacherous disease and hence, however mild, 
the attack should not be neglected. Appreciating its high com- 
municability and its tendency to many and grave complications, 
every effort should be made to arrest further spreading of the 
disease by strict isolation of the patient. Attention should be 
paid to the prevention of complications, principally pneumonia 
and otitis, — the first by avoiding exposure of the patient to bad 
atmospheric changes, the second by early treatment of the naso- 
pharynx — which in the majority of instances serve as the causal 
factors of grip meningitis, and less serious complications and 
sequelse. Daily examination of the urine is a highly commendable 
diagnostic and prophylactic procedure, especially in the so-called 
chronic grip which is prone to be followed by nephritis. Rest in 
bed should be enjoined as a means of prevention of cardiac 
disturbances. 

The active treatment is chiefly symptomatic. The following 
combinations are quite efficient : — 



B Natrii benzoatis 3j 

Antipyrinse 3ss 

(Codeinse gr. ss) 

Syr. althese 3iv 

Aquae q. s. ad §i j 

M. Sig. : 3j every three hours for a child 4 years old. 



4 

2 

0.03 
15 
60 



MEASLES. 291 

I^ Natrii benzoatis 3ss | 2 

Aspirini gr. xv | 1 

Olei sacch. menth. pip q. s. 

M. ft. piilv. no. viij. 

Sig. : One powder every three hours for a child 6 years old. 

H Antipyrinse salicylatis 3ss | 2 

Ft. pulv. no. viij. 

Sig.: One powder every three hours for a child 6 years old. 

For the acute cough ordinary mild expectorants will suffice. 
Protracted coughs usually yield promptly to creosote internally, creosote. 
and the tincture benzoin compound (3j to Oj of boiling water) 
by inhalation. Complications should be atended to at their 
earliest inception. Marked prostration calls for prompt stimula- Tonics. 
tion by means of wholesome diet, small doses of strychnine, and 
digitalis. A sojourn in the country will materially aid in the 
prevention of dangerous sequelae (e.g., tuberculosis). 

MEASLES 
(Morbilli, Rubeola). 

Measles is probably the most frequent and most readily com- 
municable eruptive fever of childhood. Children of from two to 
six years old are most susceptible to it, but it is not rarely met 
in older and younger ones. In the majority of instances one 
attack immunizes the patient against another one ; numerous 
exceptions, however, are on record. The cases of recurrent 
measles often prove to be rubeola on one occasion, and rubella, 
or a similar skin eruption, on another. The disease is com- 
municable in all its stages by means of the contagium — which 
dwells in the lacrimal, nasal, and bronchial secretions, and prob- 
ably also in the papules and squamse — either by direct contact or, 
more rarely, through intermediate persons, the air or fomites. 

Nine to eleven days — the period of incubation — pass after inva- 
sion of the system by the materia morbi without any characteris- 
tic manifestation of ill health, except slight anorexia, restlessness, 
ephemeral rise of temperature, etc., which toward the end lead 
to a more acute aggravation of the condition and mark the begin- 
ning of the prodromic stage. This stage usually lasts three days, 
rarely longer (up to a week in debilitated children). The little 
patient complains of chilliness, headache, and fatigue, hangs 
its head or sleeps most of the time, coughs and occasionally ^^^^L 
sneezes, and presents a rise of temperature of from 2° to 4° F. 
Not rarely the fever drops the next day, but the catarrhal symp- 



292 COMMUNICABLE DISEASES. 

toms continue in severer form. Examination of the mouth and 
Mottled throat in the majority of cases reveals upon the mucous mem- 
pa ate. i^j-^j^g q£ l-]^g gQ£^ ^j^^ hard palate diffuse redness or punctiform 
or stellate spots, and on the buccal mucous membrane from six to 
Red spots twenty, rarely more, red spots, with a central, rounded, slightly 
"Mucous elevated, bluish efflorescence. These spots never cause pain or 
mem rane. ^j^^^j-^^^^ They are called Filatow or Koplik spots — the latter 
deserving the credit of having proven the pathognomonic sig- 
nificance of the spots as an early sign of measles. 

Another twenty-four hours and the eruptive stage is reached. 
Eruption. Bright red, pinhead- to lentil-sized dots appear over the forehead, 
about the ears and over the face (chin and around the nose and 
mouth — circumoral ring), and rapidly enlarge to irregularly 
serrated, pea- and bean-sized, sharply circumscribed, rounded or 
crescentic, slightly elevated red spots, which disappear on pres- 
sure. From these points the eruption rapidly spreads, often in 
crops, over the body and limbs, taking about twenty-four hours 
to complete the process. At this time the catarrhal symptoms 

Conjuncti- . . . 

vitis. also are at their height. The face is flushed ; the eyes are red and 
watering and dreading light; the nasal catarrh is intense; the 
cough frequent, harsh and often barking; the voice hoarse; the 
temperature high (104° P., or higher); the urine scanty, high 
colored (diazo-reaction positive); the child is drowsy; at times 
delirious, often vomits and occasionally suffers from diarrhea 
(sometimes bloody). The peripheral and lymphatic glands are 
not rarely swollen and painful, and the spleen is somewhat 
enlarged. 

The eruptive stage lasts from five to six days. Toward the 
end of this stage the eruption begins to fade, especially on the 
face, and bran-like scales take the place of the exanthema. With 

Fine des- ' ^ 

quamation. i\^q fading of the cruption there is often a critical decline of the 
temperature and concomitant symptoms, except the bronchial 
catarrh. The desquamative stage lasts about one week, so that 
the patient is usually entirely well by the end of the fourth w^ek 
from the time of infection. Sometimes traces of the exanthema 
in the form of bluish-red spots remain over some portions of or 
the whole body which do not disappear on pressure with the 
finger. They are of no special significance. 
^Sms^ Deviations from the typical course of the disease are not rare. 

Thus, the exanthema may be absent or so scanty as to escape 
observation — morbilli sine exanthema — notwithstanding the pro- 



AIEASLES. 



293 



nounced character of the catarrhal and febrile symptoms. In 
such cases the diagnosis from the grip is almost next to impos- 
sible, and can at best only be surmised in the presence of an 
epidemic or another case of measles in the immediate sur- 
roundings. 

The eruption may appear m the form of small papules, at 
times penetrated by a hair — morbilli papiilosi; or be covered by 
minute vesicles — morbilli miliares. 

The appearance of the exanthema may be delayed for a day 
or two and then be localized principally upon the body and limbs 
or become confluent so as to resemble the rash of scarlatina — 
morbilli scarlatiuosi. Occasionally small hemorrhages occur 
between the spots — morbilli hemorrhagici. This form of measles 
is not to be mistaken for morbilli hemorrhagici maligni, "black 
measles," which is rather very rare and observed only in delicate, 
cachectic children. In this condition instead of the eruption there 
are numerous petechise and ecchymoses, in addition to hemor- 
rhages from the nose, ears, genitalia, kidneys or bowels. Malig- 
nant measles is usually associated with early depression, very 
high temperature, rapid and frequent pulse; dry, brown and 
thickly coated tongue ; sopor, convulsions and coma, and often 
ends fatally within three days. 

Occasionally the temperature is protracted or after a fall 
suddenly rises, indicating the occurrence or near advent of com- 
plications or sequelae. Ordinarily complications set in toward the 
end of the eruptive stage, but may appear as early as the pro- 
dromic stage. At this period also we are apt to find angina 
tonsillaris, epistaxis, severe vomiting and diarrhea, catarrhal 
laryngitis, pneumonia, etc. 

In the eruptive stage pneumonia forms the chief complication. 
Violent coughing is prone to give rise to laceration of the lungs 
and consecutive "pneumohypoderma" (see page 286). Quite fre- 
quently we meet also with pseudocroup and more rarely with 
diphtheria. The diphtheria of the throat sometimes develops 
secondarily to that of the conjunctiva; more frequently, however, 
the former occurs primarily, and the diphtheritic conjunctivitis 
remains limited to the original focus. It was my privilege to see 
two cases in point. One boy, six years old, succumbed to laryn- 
geal diphtheria, while his brother, three years old, was saved 
from blindness and, perhaps, death, by early administration of 
antitoxin. The affected eye presented a clinical picture resem- 



Resembles 
influenza. 



Scarlatini- 
form. 



Black 
measles. 



Croup. 
Pneumonia. 



Diphtheria. 



Antitoxin. 



294 COMMUNICABLE DISEASES. 

bling that of gonorrheal ophthalmia. The diphtheritic conjuncti- 
vitis cleared up entirely within ten days, but was followed by 
typical diphtheritic paralysis of the throat. Severe stomatitis is 
Noma. ^^^ uncommon, and numerous cases of noma (q.v.) compHcating 
or following measles are on record. The same observation holds 
good for divers forms of ear affections. Measles is not infre- 
quently associated with typhoid, erysipelas, varicella, scarlatina 
and acute pemphigus. The latter eruption may become gan- 
grenous and prove fatal. The tendency to gangrene of apparently 
mild lesions of the mucous membranes and skin should always be 
borne in mind, as it is not at all rare to find general sepsis super- 
vening just such lesions. Measles acts as a great predisposing 

PGrtussis 

cause to pertussis, which latter may prove fatal from rapid col- 
lapse or early supervention of bronchopneumonia. Sudden heart 
paralysis is rare. 

Among the sequelae the following affections deserve special 
otitis, emphasis : Chronic conjunctivitis, keratitis, otitis, deafness, deaf- 
mutism, osteomyelitis, purulent pleurisy, or pericarditis, nephritis. 
Tuberculosis, tubcrculosis, psychoses, meningitides and other nerve affections. 
Fortunately, most of the aforementioned complications and 
sequelae are rare. Ordinarily measles runs a benign course. 
Still, measles should always be looked upon as a very serious 
disease, especially if it attacks very young and delicate children 
and those with a tainted hereditary disposition. 

The custom still prevailing with some ignorant people to con- 
-r , x- ^ gregate the children free from measles with those affected by it 

Isolation of ° ° 

patient, so that ''they should all have it at once" is condemnable. Isola- 
tion of the patient should be insisted upon, and all other precau- 
tions available (see page 88) strictly adhered to. 

The special measures in the treatment of measles consist 
Dia heretics pi"incipally of activc diaphoresis by hot drinks, hot baths and 
diaphoretics (decoction of crocus, 3j to Oss), and minute doses of 
Anodynes. ^^ opiate and expectorants to relieve and loosen the cough. 
Attention to complications is all important, whether grave or 
mild. A light diet should be enforced as long as the temperature 
is above normal. The fear of free ventilation of the sick-room is 
unfounded. On the contrary, a liberal supply of fresh air should 
be allowed as a therapeutic measure. Where photophobia exists, 
the room should be darkened by shades. 

The mouth and eyes should be kept clean with warm boric 



ROTHELN. 295 

acid solutic::?, and the nasopharynx by instillations of a few 
drops of albolene. 

Other symptoms arising should be treated according to indi- 
cations. 

Ij^ Liq. amnion, anisat 3ss | 2 

Spts. aetheris nitrosi, | 

Syr. scillse comp., j 

Tinct. opii camphorse aa 3j | 4 

Syr. rhei 3iv j 15 

Aq. anisi q. s. ad §ij j 60 

M. Sig. : 3j every three hours for a child 4 years old. (Useful 
expectorant, etc.) 

For differential diagnosis see page 327. 

ROTHELN 

(German Measles, Rubella, Epidemic Roseola). 

On superficial examination rotheln closely resembles measles, 
but on careful observation it is found to differ from it in so many 
respects as to justify its classification into a distinct disease. It 
is highly communicable and often occurs in epidemics. One 
attack is supposed to confer immunity for life ; the exceptions to 
this rule, however, are by far more numerous in this disease than slight 

' ^ -^ prodromata. 

m measles. The incubation period lasts from ten to twenty-one 
days, and is generally free from any manifestations. There are 
none or very slight prodromata of from twenty-four to forty- 
eight hours' duration, consisting of languor, anorexia, and slight 
catarrhal symptoms. The eruption usually appears suddenly 
first on the face, and within from twelve to twenty-four hours 
over the entire body. Often it has disappeared from the face by 
the time the extremities are involved. The rash appears in tzvo ^stL^^^^^°^°^ 
forms. One resembles that of measles — pale red papules, up to 
the size of a lentil, usually discrete, rarely confluent, and momen- 
tarily disappearing on pressure. The other form is finely punc- 
tuate and coalesces into diffuse rose-red patches — resembling the foTm^rash. 
rash of scarlatina. The eruptive stage lasts from three to four 
days, and is usually free from severe general symptoms. During 
the height of the exanthema, there may be a rise of temperature 
of two or three degrees, but it is only of short duration. As in 
measles, the mucous membrane of the throat is the seat of diffuse 
or dotted redness ; the buccal mucous membrane, however, shows 
no typical Koplik spots. Most patients complain of sore throat ^^ .^^^ 
during the acme of the disease, but not nearly as much as in 



296 



COMMUNICABLE DISEASES. 



Adenitis. 
Large spleen. 



Free per- 
spiration 
patho- 
gnomonic. 



Complica- 
tions. 



scarlatina. The superficial glands, particularly those in the 
region of the angle of the jaw and less frequently those of the 
axilla, groin, etc., and the spleen are enlarged and tender. 

The differential diagnosis between rubella and rubeola will 
be outlined on page 327. Attention will here be directed, how- 
ever, to the frequent, nay, almost constant, occurrence of free 
perspiration in rotheln, a symptom almost never met in genuine 
measles. Where the rash is scarlatiniform, it may in the begin- 
ning be confounded with scarlet fever, but in the latter affection 
there are marked initial symptoms (vomiting!), high fever and 
pulse, and more severe throat manifestations. 

Numerous so-called heat and stomach rashes greatly resemble 
German measles and it is not always very easy to tell them apart, 
particularly in the absence of an epidemic of rotheln. Under the 
circumstances it is safe to reserve the diagnosis for about twenty- 
four hours, and watch the results of a "cooling lotion" and a 
laxative. 

For its dift'erentiation from Duke's disease see page 327. 

Rubella is considered the mildest of all acute exanthematous 
infectious diseases, and, as a rule, terminates favorably within one 
week from the onset of the symptoms. But in view of the occa- 
sional occurrence of serious complications (severe angina, bron- 
chopneumonia, suppurative adenitis, and even meningitis), it 
should always receive proper attention, especially in the way of 
rest in bed, light diet, cleansing of the nasopharynx, and good 
hygiene. See also the treatment of measles, page 294. 



DIPHTHERIA. 



Diphtheria 
bacillus. 



Diphtheria is caused by a bacillus discovered by Klebs and 
Loffler in 1883. The bacilli are found in the secretions and 
excretions of the structures involved, and are transmitted usually 
through direct personal communication (kissing, etc.), but prob- 
ably also through the agency of dishes, clothing, etc., and through 
a third person. The bacillus is very tenacious to life, so much so 
that rooms previously occupied by diphtheria patients and left 
vacant for weeks frequently harbor infective diphtheria bacilli, 
having resisted disinfection and prolonged ventilation. 

The diphtheria bacilli have a predilection for the lining of the 
nasopharynx and larynx, especially of children of from two to 
eight years of age. By far more seldom they attack other parts 



DIPHTHERIA. 



29^ 



of the body, e.g., intestines, by extension of the primary inflamma 
tion. After imbedding themselves into the primarily affected focai 
structures the bacilli multiply and secrete their toxins, which 
enter the tissues and lymphatics and thence produce general 
infection. 

The incubation period varies from five to ten days. As a rule, 
the onset is sudden with vomiting, headache, chills, fever, sore 
throat, and difficulty in swallowing. Not rarely however it is 
preceded by indefinite signs of ill health of a few days' duration, 
consisting of anorexia, lassitude, slight fever, irritation of the 



Primarily 




Fig. 80. — Diphtheria or Klebs-Loffler bacilli ; smear prepara- 
tion from tonsillar deposit. Loffler's stain. X 800. {Lenhart:: 
and Brooks.) 



respiratory tract, etc. In such cases the active stage of the dis- 
ease may insidiously follow upon the prodromic stage without 
any pronounced variation in the clinical manifestations, the throat 
symptoms often remaining latent until discovered by a routine 
examination of the throat or immasked by grave correlative symp- 
toms. The importance of a routine examination of the throat of 
children in all kinds of complaints, therefore, is obvious. 

The initial symptoms of the disease are not very characteristic, 
especially if the attack is mild. The uvula and tonsils are 
inflamed and somewhat enlarged. Careful inspection of the 
throat usually reveals upon the inner tonsillar or faucial surfaces 
a small, imeven, grayish-white, slightly elevated patch, or a few ^^f^^ 
gray streaks or hemorrhagic specks. Within a few hours the 
deposit is found to have spread to the palatine arches and the 

19a 



Deposit on 
inner ton- 
sillar and 



298 COMMUNICABLE DISEASES. 

posterior pharyngeal wall, giving the appearance of a greenish- 
Raw, bleed- white, sharply defined, firmly adherent membrane, which if for- 
ing surface. ^,j|^|y detached leaves behind a raw, bleeding surface, and re-forms 
very soon after. As the deposit assumes greater dimensions, 
the cervical and submaxillary glands, which at first are but 
slightly involved, become large and hard, assume the shape of 
large walnuts, and are very painful to the touch. Deglutition is 
difficult but not very painful — due to partial degeneration of the 
pharyngeal muscles and their nerves. The aforementioned con- 
stitutional symptoms continue. 

The symptomatology thus far represents the first stage of a 
moderately severe attack of pharyngeal diphtheria. From now 
on three eventualities are possible: 1. The clinical picture may 
remain stationary. 2. The disease may spread to the nose. 3. 
Involve- The diphtheritic process /may extend downward to the larynx, 
larynx. Since the introduction of the antitoxin treatment of diphtheria 
the number of cases falling into the first category has enormously 
increased. With early treatment the disease is rapidly arrested, 
the membranes are cast off spontaneously, and the patient makes 
an uneventful recovery within from four to eight days. Less 
frequently the second or third possibility occurs. Either as a 
result of extreme virulence of the infection or of negligence or 
improper treatment, the nose or larynx or both become invaded. 
Nasal sero- In nasal diphtheria (rhinitis fibrinosa et membranacea), in addi- 
discharge. tioii to the previously mentioned symptoms, nasal breathing is 
obstructed and accelerated. The child keeps the mouth widely 
open, snores, is very restless, speaks through the nose, is almost 
unable to swallow, has foetor ex ore, and coryza with a sero- 
purulent discharge. In laryngeal involvement (diphtheritic 
croup), symptoms of laryngeal stenosis predominate. The child's 
voice becomes husky, then hoarse, aphonic, and its breathing 
noisy, rough and wheezing, and as the disease advances it is 
True croup, attacked by a barking, croupy cough, dyspnea, retraction of the 
lower portion of the sternum and the ribs with each inspiration, 
and cyanosis. The dyspnea often occurs in paroxysms, which 
greatly resemble those of spasmodic croup (q. v.), and grow 
worse from time to time. Unless the air passages are promptly 
freed from the obstruction by intubation or tracheotomy, the 
patient passes into a state of stupor and finally succumbs to the 
effects of increase of carbonic acid and deficiency of oxygen in 
the lungs. 



DIPHTHERIA. 299 

Both laryngeal and nasal diphtheria may develop primarily, 
and later become associated with pharyngeal diphtheria. 

The course of the disease varies greatly with the location of 
the lesion, severity of the attack, and the period at which treat- 
ment is begun. Pharyngeal diphtheria usually pursues the most Prognosis 
favorable course. Mild cases, as mentioned, may end in complete gea^ ^^^^' 
recovery in from four to eight days. In severer cases the symp- favorable, 
toms may increase in intensity up to the fifth or sixth day, and 
then begin to abate, and after a rapid or protracted course finally 
subside. The same holds true of nasal or laryngeal diphtheria, 
provided treatment is instituted early and no complications super- 
vene. Unfortunately in the latter form of the disease complica- 
tions are of quite frequent occurrence. Exhausted from the 
prostrating effects of the paroxysmal attacks of laryngeal stenosis, 
the child is unable to withstand the onslaught of the diphtheritic 
poison (sometimes also mixed diphtheritic and streptococcic 
infection). The deposit, originally limited to the upper portions 
of the larynx, rapidly extends downward, involving the trachea 
and bronchi — leading to croupous bronchitis and pneumonia, and, 
as a rule, to a fatal issue — and upward, exerting its destructive 
action upon the pharyngeal, oral and nasal structures, often Malignant 
resulting in perforation of the palate, gangrenous sloughing of 
the uvula, etc. These cases of so-called diphtheria gravissima s. 
maligna sometimes develop very slowly and insidiously (diph- f^^^^ 
theria larvata) with symptoms of slight indisposition, slight rise 
of temperature, bronchial or gastrointestinal catarrh, and after 
a period of from a week to ten days are abruptly announced by 
true croup and the accompanying grave manifestations. Occa- symptoms. 
sionally this form of the disease pursues a septic course right 
from the start, — irrespective of the location and extent of the 
deposit. It is characterized by vomiting, prostration, puffiness and 
earthy pallor of the face ; small, often irregular pulse ; epistaxis ; 
bleeding from the mouth, pharynx or into the skin. The urine is 
scanty, loaded with albumin ; the temperature may be slightly 
raised or below normal. Within from three to five days the child 
dies, in a state of low muttering delirium, from gradual exhaus- 
tion, or earlier from cardiac paralysis. On post-mortem examina- post-mortem 
tion, in addition to the diphtheritic lesions pathognomonic of all ^ ^^^^" 
forms of the disease, the spleen is found enlarged; the kidneys, 
liver and heart in a state of cloudy swelling — a group of patho- 
logic findings ordinarily met in severe infectious diseases — and, 



300 COMMUNICABLE DISEASES. 

varying with the intensity and number of compHcations, divers 
lesions in other organs of the body (e.g., lungs, brain and alimen- 
tary canal). 

There is nothing definite about the number and severity of 
the complications in any given case. As already stated, mild 
cases may become severe and exhibit all sorts of complications 
and sequelae and, vice versa, cases with severe onset may under 
proper treatment remain free from either and end favorably in 
a comparatively short space of time. Kidney, heart, lungs and 
nerve diseases form the most frequent complications and sequelae. 
albuminuria. Transient albuminuria is often observed even in mild cases. It 
usually begins the third or fourth day of the disease, sometimes 
earlier or later, and disappears with abatement of the other diph- 
theritic symptoms. Occasionally we find true nephritis diph- 
Nephritis. theritica, with large quantities of albumin and casts and more 
rarely also blood. The nephritis may also set in as a late sequel, 
during apparent convalescence, and remain more or less perma- 
nent. As a rule, however, the nephritis is of short duration, and 
rarely gives rise to local or general dropsy. By far more 
serious is the accompanyins^ heart affection — so-called "heart 

Heart- . . „ . . . ^ ^ , , . ^ . 

paralysis, paralysis from involvement of the pneumogastnc nerve, it is 
often manifested by sudden heart-failure, and may set in either 
during the acme of the disease or any other time between then 
and as late as from four to six weeks after. It is apt to arise on 
the slightest exertion. The heart paralysis is not invariably 
sudden and fatal, however. Quite often it is preceded by heart- 
weakness with symptoms of dilatation^interstitial myocardial 
degeneration — such as extreme pallor; feeble, rapid, and irregular 
pulse ; attacks of syncope, albuminuria, exhausting diarrhea, some- 
times apathy, somnolence, sopor and death ; or, less frequently, 
very slow convalescence, and gradual recovery, usually with 
remaining heart disease. Occasionally diphtheria is complicated 
Endocarditis. \yy pericarditis or endocarditis. Bronchitis and pneumonia are 
especially prone to occur in laryngeal diphtheria, as a result of 
direct extension of the diphtheritic process to the trachea, bronchi, 
etc. (in intubated cases through entrance of foreign bodies. 
Aspiration P^rticlcs of food, ctc, into the air-passages — ''aspiration pneu- 
pneumonia. monia"), but also in other forms of the disease. The occurrence 
of pneumonia greatly mars the prognosis. 

The most frequent sequel — occasionally also complication — of 
diphtheria is multiple neuritis, "diphtheritic paralysis." It is due 



DIPHTHERIA. 301 

to an intense defeneration of the peripheral nerves up to their Multiple 

^=5 r 1 r neuritis. 

roots. It follows in about one-tenth of all cases, probably mild 
and severe alike. It generally develops about the third or fourth 
week after the onset of the diphtheria, sometimes earlier or later, 
and affects the muscles of the soft palate by preference, causing^ 

. . . Regurgita- 

a nasal tone of voice, and ree^ure^itation of fluids throug;h the tion of 
nose. In combined esophas^eal and laryno^eal paralvsis there is through 

. . . . . ' . the nose. 

also great difficulty in deglutition, not rarely giving rise to "aspira- 
tion pneumonia." as a result of entrance of part of the food into 
the air passages. These disturbances usually disappear spon- 
taneously or on suitable treatment, within from four to six 
weeks. The paralysis may extend to the eye-muscles and cause 
strabismus, oculomotor paralysis, disturbance of accommodation strabismus. 
and even total ophthalmoplegia. Less frequently the muscles of 
the trunk and extremities are implicated. The symptoms result- 
ing are more or less identical with those observed in cases of 
multiple neuritis from other causes, and vary in intensity from 
simple motor weakness and ataxic gait up to hemiplegia. In Ataxia, 
severe cases the tendon reflexes and faradic irritability are 
entirely lost, and the muscles undergo atrophy. Nevertheless, 
recovery is the rule in the majority of instances, except when 
complicated by paralysis of the respiratory muscles (diaphragm) 
and the aforementioned baleful sudden heart-failure. As regards 
the hemiplegia, it is still uncertain, whether it is a genuine diph- Hemiplegia, 
theritic paralysis or caused by underlying alteration in the 
brain, such as cerebral hemorrhage, or cardiac thrombosis with 
embolism of the arteria foss^ Sylvii, since the hemiplegia not 
rarely begins with convulsions, loss of consciousness, and is often 
associated with aphasia and facial paralysis. If the patient sur- 
vives the attack the hemiplegic symptoms usually subside within 
a few weeks, but weakness and contractures of the extremities 
may remain permanent. 

Less common complications and sequelae are arthritides. involvement 
otitides, pleuritis, peritonitis, suppurative adenitis, diphtheritic Jract^^^^^^^^' 
affections of the stomach, various rashes, etc. 

From the foregoing discussion it can readily be appreciated 
that a positive prognosis is almost impossible. It should always 
be guarded, no matter how mild the case. The gravity of the 
epidemic, the severity of the attack, the strength and age of the 
patient, the quality of the heart, the period at which antitoxin has 
been administered — all have an important bearing upon the out- 



302 



COMMUNICABLE DISEASES. 



Immuniza- 
tion 



come of the case. However, no case should be despaired of, no 
matter how grave. Antitoxin treatment often performs miracles, 
even in apparently hopeless cases. 

With the advent of the serum treatment, diphtheria has ceased 
to be the dread of the community. The mortality of diphtheria 
which previously ranged between 50 and 75 per cent., has now 
dropped to about 5 per cent, in pharyngeal and to 20 per cent, 
in laryngeal diphtheria — the earlier the serum treatment is begun 
with the lower the mortahty. Indeed by administering diphtheria 
antitoxin at the very inception of the disease we are often enabled 
to limit the latter to its local manifestation — almost free from 
constitutional symptoms. Furthermore, those coming in close 
contact with the diphtheria patient may by means of from 500 to 
1000 units of antitoxin be immunized against this affection for a 
period of from four to six weeks. 

This procedure and isolation of the patient are the most 
Isolation, potent prophylactic measures of diphtheria. As the nasopharynx 
forms the principal nidus for the development and spread of the 
diphtheria bacilli and their toxins, cleansing of the nasopharynx 
by means of mild antiseptics (instillation of Dobell's solution 
three or more times a day) will often aid in the prevention of 
infection. This prophylactic measure should be employed in con- 
junction with immunization by antitoxin, or without the latter — 
wherever there are contraindications to its use {e.g., status 
lymphaticus, hemophilia) or objections on part of the family. 
Heart disturbances being the most dangerous complication of 
diphtheria, the heart should receive very careful attention, even 
in the mildest form of the affection. It should be examined daily, 
especially as regards acute dilatation of the heart. The patient 
should be kept under observation for at least four weeks after 
abatement of the acute course of the disease, and in the event of 
any untoward symptoms arising, immediately be put to bed and 
treated in accordance with the directions presently to be outlined. 
Even with an apparently normal heart it is imperative to keep the 
child perfectly at rest in bed for at least ten days after disappear- 
ance of the local symptoms. As to the prevention of ''aspira- 
tion pneumonia," the reader is referred to the chapter on 
'Tntubation." 

The active treatment of diphtheria can be summarized in a 
few words : Counteract the diphtheria toxin ; arrest the local 
lesion, and increase the power of resistance of the patient. When 



Contra- 
indications 
to antitoxin. 



Perfect rest. 



DIPHTHERIA. 303 

called upon to see a case of sore throat or laryngitis that is 
strongly suspicious of being diphtheritic in nature, we should 
immediately administer diphtheria antitoxin and lose no time in 
waiting for the results of a bacteriologic examination. The senmi Mode of 
should be administered by deep hypodermic injections, a syringe tion.^"^^ ^^' 
somewhat larger than the ordinary hypodermic syringe being pref- 
erably employed for this purpose. The anterior surface of the 
abdomen or thorax or the outer surface of the thigh, where there 
is an abundance of subcutaneous cellular tissue, is generally 
chosen for the injections. Previous to the administration of the 
antitoxin the skin should be carefully washed with alcohol or 
some disinfecting solution and the syringe carefully sterilized. 
Nowadays the serum is obtainable in clean, hermetically sealed 
syringes, rendering their sterilization unnecessary. Children Dose of 
under two years of age should receive from 2 to 3000 units of 
antitoxin, and those over this age from 4 to 5000 units. Equal 
or smaller doses may be given after about eight hours, if no 
improvement is observed. In inalignant cases,i or in those seen 
late, double doses should be administered at once and if neces- 
sary repeated. The effect of the serum is very beneficial, nay, 
sometimes magical. After a temporary rise, the fever often falls 
by crisis, the pulse improves, the membranes loosen and disap- 
pear, and the whole aspect of the case sometimes changes com- 
pletely, for the better, within from eighteen to twenty-four hours. 
However, notwithstanding all that was said in favor of the anti- 
diphtheritic serum, it is not always advisable to depend upon the 
serum alone. 

As diphtheria is originally a local affection and the secretion Local 
and absorption of the metabolic products (toxins) occur from 
the local lesion, the urgency of the immediate destruction of the 
bacilli at their point of entrance is self-evident. This is best 
accomplished by the different germicides and solvents, such as 
peroxid of hydrogen, strong solutions of carbolic or salicylic acid, 
20 per cent, to 50 per cent, solutions of resorcin in alcohol, papain Resorciu- 
or pepsin, or the carbol-camphor solution referred to on page 242, 
Milder solutions of the same preparations should be used also for 
cleansing the nose — even in the absence of any lesion there. The 
local treatment should be repeated every two to four hours and 
continued until total disappearance of the acute symptoms of 
the diphtheria. 



1 In desperate cases the antitoxin may be administered intravenously. 



Feeding. 



Alcoholic 
stimulants. 



Strychnine. 



Digitali 



304 COMMUNICABLE DISEASES. 

R. Glycerit. papain 3iv I 15 

Acid, carbolic, j 

Pulv. camphor aa gr. viij | 0.5 

Alcoholis q. s. ad solv. | 

Glycerini q. s. ad f §ij | 60 

This is applied to the throat by means of a cotton swab every 
two hours — changing the swab each time — diminishing the fre- 
quency of applications with the abatement of the severity of the 
symptoms. 

The third indication, to increase the power of resistance of 
the patient, should be met by an abundance of nutritious, easily 
digestible food, stimulants and hematinics. Feeding of the little 
patient is as difficult as it is important. As a rule, total anorexia 
prevails, and it requires a great deal of patience and tact to 
induce the child to swallow a few mouthfuls of milk, broth, beef- 
juice, ice-cream, fruit-juices, etc. Still, much may be gained by 
administering the nourishment in small, frequently repeated quan- 
tities, and in small children, if need be, by rectal alimentation 
(peptonized milk). As a food and stimulant good wines and 
cognac are of inestimable value in diphtheria, especially in the 
septic variety. In malignant cases it should be given well diluted 
in large, frequently repeated doses (3j to 3ij every two hours) 
preferably by mouth, and in urgent cases in smaller doses also 
hypodermatically. It is advisable to employ mild stimulation 
from the earliest inception of the disease, and to continue it for 
weeks after in order to obviate — at least to a certain extent — 
sudden heart-failure. A useful combination which acts both as 
stimulant and hematinic, is the following: — 

I^ Strychninse snlph gr. % I 0.01 

Liquor, ferri et ammon. acetatis Bij j 60 

M. Sig. : One teaspoonful every six hours, diluted in sweetened 
water. 

Whenever the local as well as systemic effect of iron is 
desirable, the iron and myrrh mixture referred to on page 319 
answers the purpose admirably. Any untoward symptoms aris- 
ing should be combated according to indications. In heart 
weakness strychnine and digitalis should be pushed to full 
tolerance. 

In laryngeal diphtheria without nasopharyngeal lesions the 
local treatment outlined for the pharyngeal involvement may be 
dispensed with. Occasional cleansing of the nose and throat with 
Dobell's solution, however, is useful as a preventive measure. 



DIPHTHERIA. 305 

It is of advantage also to have the patient inhale medicated 
vapors, such as the following : — 



I^ Thymolis gr. x 

Acidi carbolici 3ss 

Olei eucalypti 3j 

Alcoholis q. s. ad 5i j 

M. Sig. : 3j in a pint of hot water. 



6 Inhalations. 

2 
4 
60 



Emetics. 



O'Dwyer's 
invention. 



\Mth early administration of antidiphtheritic serum the 
laryngeal stenosis rarely attains such severity as to demand relief 
by intubation or tracheotomy. ]\Hld paroxysmal attacks of 
dyspnea often yield to emesis (3ss of wine of ipecacuanha, or 
gr. ^20 of apomorphine hydrochlorate ), and a small dose of 
morphine ( gr. I50) and atropine (gr. ^500)- But if these 
remedies fail, intubation or tracheotomy should be resorted to. modiS^' 
It is always preferable to intubate (or tracheotomize ) early than 
late. \Mienever the dyspnea is steadily increasing in intensity 
and the temperature rises, this life-saving measure is indispen- 
sable, and procrastination is apt to prove fatal. 

INTUBATION.i 

For intubation as now performed the world is indebted to 
the late Joseph O'Dwyer. of Xew York. Intubation is employed 
in acute laryngostenosis whether of diphtheritic or other nature 
(see page 2561. It consists in the introduction of a tube into the 
larynx, the size of the tube varying with the age of the child. 

A set of intubation instruments (O'Dwyer's) suitable for 
children up to the age of puberty consists of six tubes, an intro- 
ducer, an extractor, a mouth-gag, and a scale of sizes. O'Dwyer's 
latest tubes are made of hard rubber and lined with gold-plated 
metal. Each tube is supplied Avith an obturator, one end of 
which screws on the introducer. The tube is selected according 
to the age of the patient, — the smallest size for the hrst year, 
the second for the second year, the third for from two to four 
years, and the others, successively, for children two years older. 
It should be remembered that the tube must lit the larynx and the 
latter not be made to fit the tube. 

Mode of Operating. — A tube of proper size for the child's 
age is selected, and, through the eyelet intended for the purpose, 
threaded with strong silk- or linen-thread. — long enough to 
reach the stomach and still protrude through the mouth. The 



1 Partly after Graetzer and Sheffield's ''Practical Pediatrics.' 

20 



306 COMMUNICABLE DISEASES. 

thread is used as a precaution to prevent the tube from sHpping 
into the stomach, in case it is wrongly placed into the esophagus 
instead of the larynx. 

The obturator is then screwed tightly to the introducer and 
passed into the tube, and by repeatedly pushing the latter off from 
and replacing it upon the introducer we determine that the instru- 
ment is in working order. 
Preparation The patient is now placed upon a strong table and the body, 
from shoulder down, is wrapped snugly in a small sheet or 
blanket retained in position by several safety pins. 

An assistant standing at the head of the table inserts the 
gag in the left angle of the child's mouth, well back between the 



of patient. 




Fig. 81. — Introducer with Tube and Detached Obturator. 

teeth, and opens the gag as widely as possible without using too 
much force. The same assistant steadies the patient's head and 
holds the gag in situ. 

The operator standing to the right and in front of the patient 
Introduction holds the iutroduccr liqhtly between the thumb and fingers of the 

of tube. c -7 o 

right hand, with the thumb resting just behmd the button that 
serves to detach the tube, and the index finger in front of the 
trigger underneath. 

The index finger of the left hand is now quickly passed into 
the pharynx down to the beginning of the esophagus and, by 
bringing the finger forward in the median line and raising and 
fixing the epiglottis, the tube is gently introduced, along the left 
index finger, into the larynx. 

When the tube is inserted, it is slipped off by pressing forward 
the button on the upper surface of the handle with the thumb, 
while counterpressure is made with the index finger under- 
neath. In removing: the obturator the tube must be held down 



DIPHTHERIA. 



307 



by placing the finger either on the side or posterior portion of the 
shoulder of the tube, lest the tube will be pulled along. After 
placing the tube in position the gag is removed, but the string is 
allowed to remain for about ten minutes, or until it is ascertained 
that the dyspnea is relieved and that no loose membrane is 
crowded down in the lower portion of the trachea. In removing 
the thread the finger is reinserted to hold the tube in place. 

If any difficulty is experienced in locating the epiglottis, it is 
better to seek the cavity of the larynx, a cul-de-sac into which 
the tip of the finger readily enters, and which cannot be mistaken 
for anything else. Once in this cavity, the epiglottis must be in 
front of the finger, and the latter is then raised and carried to the 



Removal of 
obturator. 



Removal of 
thread. 



Localization 
of epiglottis. 




Fiff. 82. — Extiibator. 



patient's right in order to leave room for the tube to pass beside it. 

In the beginning of the operation the handle of the introducer 
is held close to the patient's chest, and then rapidly raised as the 
lower end of the tube passes behind the epiglottis ; otherwise it 
slips over the epiglottis into the esophagus. 

After-treatment. — The patient should be kept in a recum- 
bent or upright position, but not allowed to lie upon the face or 
upon the nurse's shoulder, face downward. After about two 
hours feeding (in very small quantities) may be resumed, — 
nursing infants at the breast or bottle, and older children with 
semisolid substances, such as custards, matzoon, wine jelly, 
scrambled eggs, ice-cream, etc. It is of advantage to feed while 
the patient's head is lower than the body. The presence of the 
tube in the larynx does not contraindicate the use of emetics, 
which are sometimes needed when the bronchi are loaded with 
secretions. 



Feeding. 



308 COMMUNICABLE DISEASES. 

Accidents and Dangers of Intubation. — With the experi- 
enced operator the principal danger that may attend intubation 
membrane^ is asphyxia from existence of loose membrane below the tube, 
that is, in the lower portion of the trachea. If this occurs the 
tube should immediately be withdrawn and, after clearing the 
trachea of the membrane by induction of expulsive coughing or 
emesis, reinserted. There is rarely any danger from repeated 
failure to intubate, provided the operation is performed without 
passage, such forcible manipulation as to produce a false passage, and the 
finger is not retained in the pharynx longer than ten seconds at 
a time, and the child is given a chance to get its breath between 
the attempts. 

Removal of the Tube. — The condition of the child being 
favorable, the tube is ordinarily removed after from five to seven 
days. This is accomplished with the patient in the same position 

Introduction -^. . . ^, . • , , , , • , i r 

of extractor, as lor mscrtiou. ihe extractor is guided along beside the nnger, 
which is first brought in contact with the head of the tube (be 
sure that the tube is still there!) and then carried to the right in 
order to uncover the aperture by lifting the epiglottis and to leave 
room for the instrument to enter beside it. Occasionally one 
succeeds in removing the tube by "stripping" the larynx from 
below upward with one hand and grasping the head of the tube 
between the index and middle fingers of the other hand. 

Retained Intubation Tube (Prolonged Intubation). — Occa- 
sionally cases are met in which removal of the tube is imme- 
diately followed by asphyxia, though otherwise the patient seems 
in good condition. This is sometimes remedied by the use of 
Sedatives, scdativcs internally and a spray of cocaine locally to relieve the 
spasmodic laryngeal stenosis, if present; or by gradual intro- 
duction of larger and larger intubation tubes anointed with some 
antiphlogistic drug (5 per cent, ichthyol). 

The Advantages of Intubation over Tracheotomy. — 1. With 
an experienced operator, it is a bloodless operation. 2. No fresh 
wound is made which may prove a new avenue of infection. 3. 
No anesthetic is required, hence no shock or exhaustion from 
operation. 4. No skilled after-treatment is needed; no granula- 
tion wounds to treat. 
fOT^r^che- Tracheotomy is indicated whenever the larynx is obstructed 
otomy. i^y foreign bodies, edema of the glottis, tumors (e.g., multiple 
laryngeal papillomas, or compression tumors from neighboring 
structures) and cicatricial construction of the larynx. (See 
page 259.) 



DIPHTHERIA. 309 

DIFFERENTIAL DIAGNOSIS. 

1. Pharyngeal Diphtheria, — {a) PscudomcmbraJic : Hi phar- 
yngeal diphtheria the pseudomembrane appears as a small, 
uneven, grayish-white, slightly elevated patch upon the inner 
tonsillar or faucial surfaces of the throat. The deposit — which 
contains diphtheria bacilli — augments by quick spreading, 
reaching within a few hours the posterior wall of the pharynx, 
and, in severe cases, the Eustachian tube, nares, and, more Extensive 
rarely, the conjunctiva. Anteriorly the pseudomembrane 
attacks the palatal arch and uvula. It may spread downward 
into the larynx or alimentary canal. The surrounding un- 
covered areas are grayish in color, due to overcrowding of 
leucocytes, nuclei, and mucus beneath. The tonsils, as a rule, 
are but slightly enlarged. The deposit, if removed, leaves a 
raw. bleeding surface and re-forms rapidly. 

In follicular amygdalitis the deposit begins as one or more 
white, small pellicles upon the middle or anterior portion of tjie smaii, iso- 
tonsil. The pellicles, at first distinctlv isolated, graduallv coalesce, gradually' 

1 1 1 -ni ' 1- • 1 1 "^ -1 coalescing. 

tormmg elevated patches. I hey are limited to the tonsils, may 
easily be removed, and reform slowly. The tonsil, usually one, is 
moderately enlarged, sometimes previous to the appearance of 
the deposit. 

In parenchymatous amygdalitis the tonsil is greatly enlarged, 
often displacing the uvula. It is bluish in color and doughy in 
consistence. The deposit, at first white, soon becomes vellowish, "Point" of 

' abscess. 

resembling the "point ' of an abscess. 

In lierpetic amyqdalitis the deposit bes^ins with minute A'esicles, 
which have a tendency to burst and leave superficial ulcers. This vesicles. 
form of amygdalitis is at times accompanied by stomatitis. 
Otherwise it resembles follicular amygdalitis. 

In necrotic amygdalitis the tonsils are moderately enlarged 
and the deposit lies deeply imbedded within the structure of the 
mucous membrane. The deposit, if removed, leaves behind a 
deep ulcer — sometimes gangrenous — surrounded by a distinct red ^i^^^- 
zone ; it spreads, as a rule, from one tonsil to the other by way of 
the anterior pillars and palatal arch, frequently attacking also 
the uvula. 

(b) Submaxillary Glands: The submaxillary glands in diph- 
theria are greatly involved. They are large and hard, assuming ^^^<^- 
the shape of a large walnut, and can easily be seen protruding 
from the angle of the jaw. They are very painful to the touch. 



Spreading 



Large and 



Bilateral. 



310 COMMUNICABLE DISEASES. 

In follicular and herpetic amygdalitis the glands are moder- 
Moderate. ately enlarged, softer in consistence and less painful to the touch 
than in diphtheria. 

In parenchymatous amygdalitis the glands are moderately 
Diffuse, enlarged and diffuse, the swelling often extending as high as the 
ear. 

In necrotic amygdalitis the glands differ but slightly from 
Unilateral thosc of diphtheria and cannot be relied on as a differential point 

at first. J- T 

oi diagnosis. 

(c) Early Constitutional Symptoms: Except the presence of 
albumin in diphtheritic urine, none of the early constitutional 
symptoms are characteristic of diphtheria. Indeed, they are fre- 
quently less pronounced in diphtheria than in the other throat 
affections, unless the former is complicated by streptococcic 
Moderate infection. The temperature in diphtheria, as a rule, is moderate, 
in diphtheria, about 101° to 103° F., and continuous. The pulse is feeble and 
quick and soon gives signs of exhaustion. The face, as a rule, 
is pale. Swallowing is difficult, but not very painful, due to 
partial degeneration of the muscles of deglutition and their nerve 
supply. Albuminuria is invariably present from the earliest 
beginning of the disease and is of great significance in the differ- 
ential diagnosis. 

In the various forms of amygdalitis the temperature is quite 

high, especially toward evening, often reaching 105° F. The 

Hyper- face is flushcd. Des^lutition is painful and difficult as a direct 

pyrexia m o c 

tonsillitis, rcsult of sorcuess and sensitiveness of the tonsils. Albuminuria 
is usually absent. 

The diagnosis of scarlatinal angina is at best very difficult. 
It may be taken for granted that the primary amygdalitis is 
scarlatinal in nature, and that the sore throat setting in several 
days after is diphtheritic. It should be left, however, to the 
bacteriologic test to clear up the diagnosis. 

2. Laryngeal Diphtheria. — Laryngeal diphtheria can only 
be mistaken for non-diphtheritic membratious laryngitis, also 
known as croup, which, on the other hand, is entirely distinct 
from spasmodic laryngitis (a mild catarrhal inflammation of 
the mucous membrane of the pharynx or larynx without the 
formation of a pseudomembrane). In speaking of non-diph- 
theritic membranous laryngitis I am fully conscious of the 

Differentia- . , , , , i i- • • i 

tion from mauifold denials made by advanced clinicians as to the exist- 

non-diph- ..,,..,,,. , . t 

theritic. eucc of such a nou-diphthentic disease; here, again, I am 



SCARLET FEVER. 311 

merely guided by the observations made in my own practice 
Avithout attempting either to confirm or refute the views of 
others, and, while the exact distinction is associated with 
extraordinary difficulty, I believe to hai^e been successful in 
making a correct diagnosis Avith the aid of the differential 
points referred to on page 255. 

I may also mention that pharyngeal or laryngeal syphilis in 
childhood, if accompanied by an acute attack of amygdalitis, is Differentia- 
apt to be mistaken for diphtheria. Early in the disease the his- sypmiis. 
tory of the case, the usual presence of syphilitic manifestations on 
other portions of the body and the absence of diphtheria bacilli 
are reliable differential signs. 

SCARLET FEVER 
(Scarlatina, Febris Rubra). 

The more frequently one has occasion to observe and to treat 
scarlet fever, the more he appreciates the treacherous nature of Treacherous 

disease. 

this affection. Grave danger lurks often m the most benignly 
appearing attack, and dreadful surprises are not rarely encoun- 
tered at a time when the patient is apparently at the threshold 
of recovery. It may be so mild in one child as to entirely escape 
observation, and yet may give rise to a most virulent type of the 
disease in another child. It is highly contagious and infectious 
in all its stages, the contagium (which is still unknown) being 
transmitted from person to person, through a third person, arti- 
cles in use, toys, food and the air. Children of from 2 to 7 
years are especially prone to contract the disease, but it has been 
observed even in newly born infants of mothers suffering 
from scarlatina just before delivery. As in other contagious and 
infectious diseases, some individuals possess an inherent or 
acquired permanent or temporary immunity against the disease. 
On the other hand, some children are highly susceptible to scar- 
latina and may have several attacks, sometimes even in the form 
of a relapse within from two to six weeks after the first attack 
(scarlatina reciirrens) . 

The incubation period of scarlet fever is ordinarily shorter 
than that of any of the other exanthematous febrile diseases. 
As a rule, it lasts only a few days (varies from one day to one 
or two weeks), and rarely gives rise to distinct symptoms of the vomiting. 
approaching disease. On the contrary, often in the midst of 
apparently good health, the patient vomits (usually repeatedly). 



312 COMMUNICABLE DISEASES. 

complains of fatigue, slight sore throat, and chilliness, and young 
and nervous children are occasionally attacked by convulsions. 
The temperature rises up to 103° or 104° F., or higher; the pulse 

Sore throat. IS greatly accelerated; the throat is deeply injected; the tonsils are 
somewhat enlarged and covered with a slight mucopurulent 
or hemorrhagic deposit. Sometimes a transient, prodromal 
Transient erythema is observed on different portions of the body. The 
ery ema. g^f Qj-gj^-jg^tioned symptoms continue for about twenty-four hours. 
By this time, or a few hours later, a bright-red rash becomes 
visible on the neck, chest and back and the flexor surfaces. On 
close examination the eruption is found to consist of very fine, 

scarlet rash, rosc-red to dccp-rcd dots separated by minute, pale areas of 
healthy skin. The scarlet points are not elevated above the 
surface. The rash disappears on pressure, and when the finger- 
nail or a pencil is drawn across the reddened surface, a white 
line (tachcs scarlatinale) develops which remains in situ for a few 
seconds. This is due to increased contractihty of the super- 
ficial arterioles. Gradually the eruption spreads over the entire 

circumorai body. It is Icast marked upon the face, and the circumoral ring 

ring free. 

^ — a space extending from the alse nasi to the chin — is nearly 
always free from the exanthema. The affected skin is often 
edematous. With advent of the eruption the temperature rises, 
the submaxillary glands swell up, are hard and painful to the 
touch. Inspection of the throat in the majority of instances 
reveals a follicular deposit upon the tonsils which shows a tend- 
ency to coalesce and to form necrotic patches. The tongue is 
coated, very gray, and its edges and tip are bright red. The 
papillse fungiformes soon project through the coating as red 
papules — "strawberry tongue." In accord with the height of the 
temperature, the patient is more or less thirsty, restless, delirious, 
refuses food, sometimes vomits ; his urine is scanty, high colored, 
and usually contains a trace of albumin. The symptoms thus far 
related represent the clinical picture of typical scarlatina during 
the first two or three days of the eruptive stage. As the disease 
"Straw- advances the gray deposit on the tongue is cast off, the entire 
ton^^ue' tongue is more or less swollen, red, and covered with thickened 
papillse. The deposit in the throat loses its tenacity, and often 
falls off en masse, leaving behind raw, sometimes bleeding sur- 
faces. The pulse and temperature continue quite high (103° to 
105° F.). Cases of considerable severity present in addition 
marked debility ; febrile, cardiac, systolic murmurs ; slight 



SCARLET FEVER. 



313 



Angina. 



enlargement of the liver and spleen; at times somnolence, 
delirium, with or without high temperature. On the other hand, 
mild cases by this time may be on the road to recovery, free 
from fever and rash, ready to be around and about. 

The stadium desquamativum usually sets in four or five days 
after the appearance of the eruption, and depends somewhat upon Desquama- 
the intensity of the exanthema, beginning earlier when the rash 
is pronounced. The peeling may vary from fine branny scales 
to large patches of epidermis, the coarser scales being usually 
limited to the hands and feet. Occasionally the nails shed with 
the epidermis. The peeling may last from two weeks to as many 
months, or even longer. In uncomplicated cases desquamation is 
followed by decline of the symptoms and convalescence. 

CompHcations are quite frequent, and their appearance is 
usually manifested by recrudescence of the temperature after 
defervescence. Scarlatinal angina — a necrotic inflammation of 
the throat — heads the list. It is caused by streptococcic infection 
and differs clinically from true diphtheria in that it almost never 
spreads to the larynx nor causes paralysis. Occasionally it is 
associated with true diphtheria. 

The throat involvement may be grave right from the begin- 
ning of the scarlatina, but more frequently it develops between 
the third and fourth days, usually in the form of an aggravation 
of the previous condition. The glands at the angles of the jaws 
swell enormously, are very hard and tender. Inspection of the 
throat reveals a large yellow or gray exudate on the greatly 
enlarged tonsils, and often also on the posterior pharyngeal wall. 
Scarlatinal angina often extends also to the nose, giving rise to a 
fetid, brownish-yellow discharge, and occasionally to deeper de- 
structive processes and even to necrosis of the nasal bones. Scar- 
latinal angina is a very malignant afi^ection, and frequently leads 
to a fatal termination as a result of gangrene of the throat, 
involvement of the neighboring large blood-vessels, purulent 
inflammation of the serous membranes (pleura, pericardium and 
meninges) extreme prostration, and general pyemia. In some 
epidemics one is able to distinguish two additional types of 
angina: 1. The "pestilential form," characterized by muco- 
purulent, foul masses in the throat and nose, spreading of the 
gangrenous process to the mouth and the mucous membrane of 
the lips and cheeks with consecutive hemorrhage, septicopyemic 
symptoms, increasing collapse, and fatal termination within about 



Adenitis. 



Gangrene 
of throat. 



314 



COMMUNICABLE DISEASES. 



Necrosii 
of palate 



Diphtheria 



one week. 2. "Lentescent scarlatinal diphtheroid," which sets in 
about the sixth day of the disease with sudden rise of tempera- 
ture, grave constitutional symptoms and intense swelling of the 
submaxillary glands. The local symptoms (which, by the way, 
are sometimes hidden!) in the nose and throat resemble those of 
true diphtheria, except that in scarlet fever there is a greater 
tendency to necrosis of the affected portions, and to perforation 
of the palate (as in syphilis). After stubborn persistence it quite 
frequently leads to fatal issue with symptoms of pyemia and 
asthenia. True diphtheria may be associated with any of the 
aforementioned forms of scarlatinal angina. An examination of 
the deposit for Klebs-Loffler bacillus, therefore, is always oppor- 
otitis. tune. Purulent otitis frequently arises as an immediate sequel 
of the nasopharyngeal involvement by extension of the inflamma- 
tion through the Eustachian tube and tympanic cavity. It is 
manifested by the usual symptoms of otitis media : earache, rest- 
lessness, rise of temperature, congestion and bulging of the drum 
membrane, and, as a rule, rapid perforation of the drum by the 
pus. In a great many cases the otitis leaves no serious conse- 
quences behind; in some of them, however, especially in those in 
which the escape of pus is delayed, scarlatinal otitis may lead to 
very grave consequences, such as deafness (in very young chil- 
dren deaf-mutism) mastoiditis, meningitis, etc. 

Another serious sequel of the throat affection is Angina 
Angina Ludovici: an inflammation of the submaxillary lymph-g^lands and 

Ludovici. . . ./ y r- o 

the surrounding cellular tissue of the neck, extending from the 
submental region up to the mastoid process of the temporal bone. 
The inflammatory infiltration sometimes extends to the larynx 
and produces oedema glottidis, and, by gravitation, the pus may 
enter the mediastinum and neighboring structures (purulent 
pleurisy or pericarditis). It not rarely ends fatally with symp- 
toms of septicemia, embolism or thrombosis. 

Among the earlier complications of scarlatina we may mention 
also pneumonia, rheumatism (myositis, synovitis) and endocardi- 
tis. All of these compHcations are probably of septic origin. 
The pneumonia presents nothing characteristic, may be lobular 
or lobar in type. It usually runs a shorter course than primary 
pneumonia. Scarlatinal rheumatism occurs in two forms : 
Simple myositis, i.e., a localized muscular infiltration, with sensi- 
tiveness on pressure, and vague ''wandering" pain ; and scarlatinal 
synovitis or arthritis which is manifested by pain, swelling and 



Pneumonia. 



Myositis. 



SCARLET FEVER. 315 

redness of the joints, especially those of the fingers and toes; rise 
of temperature, and other constitutional symptoms. Sometimes 
several joints are affected by leaps. As a rule, scarlatinal rheuma- 
tism is benign in nature; occasionally, however, the joints may suppurative 
undergo suppuration, leading to general pyemia with fatal 
termination. 

In association with scarlatinal rheumatism, but often also 
without this, endocarditis forms a relatively frequent complication Endocarditis. 
and sequel of scarlatina. Indeed the majority of cases of valvular 
heart disease in children, except, of course, those complicating 
primary rheumatic fever, are traceable to scarlatina. The endo- 
carditis may at first be latent and escape detection, and again 
usher in with very grave symptoms, run the course of ulcerative 
endocarditis, giving rise to emboli and metastases in the liver, 
spleen, and kidneys, and end in sudden death or permanent val- 
vular heart disease. 

The treacherous nature of scarlatina is most poignantly illus- 
trated by the occurrence of nephritis as a complication. In the Nephritis, 
midst of apparently perfect health, at a time when the eruption 
has entirely subsided, either with or without any tangible cause 
(often after a slight error in the diet), the child is suddenly at- 
tacked by headache, dizziness, sometimes vomiting, and convul- 
sions and examination of the urine reveals an interstitial inflam- 
mation of the kidneys. As the disease advances the symptoms 
enumerated under "nephritis" (q.v.) are rapidly and fully estab- 
lished. This complication usually occurs between the end of the 
second and third weeks. Hence the importance of daily examina- 
tion of the urine in all cases of scarlatina, irrespective of the 
type or degree of severity of the disease. The duration of the 
nephritis varies greatly according to its severity, and the prompt- 
ness with which it is discovered and treated. Ordinarily it lasts 
from two to four weeks and ends favorably, but relapses are not 
rare, and the nephritis may go on to chronic renal disease. In c}jj,ojjic 
fact, scarlet fever, as a rule, forms the principal cause of chronic ^[^^^^^^ 
nephritis in children. Protracted scarlatinal nephritis often gives 
rise to hypertrophy of the left ventricle and occasionally also to 
dilatation of the heart with consecutive symptoms of ruptured 
compensation (recurrent anasarca, dyspnea, etc.). Genuine 
scarlatinal nephritis should not be confounded with the transient 
albuminuria not rarely observed during the first week of scarla- 
tina, which most probably is due to the hyperpyrexia. As regards 



316 COMMUNICABLE DISEASES. 

uremia, and its grave accompaniments, the reader is referred to 
''Acute Nephritis." 

More rare compHcations are the following: Stomatitis 
Noma, ulcerosa and aphthosa, noma, gangrene and diphtheria of the 
genitalia, orchitis, vaginitis, gangrene of the skin and of the 
tapering extremities; various nerve disorders, such as meningitis, 
hemiplegia, aphasia, tetany and psychoses; conjunctivitis, iritis, 
keratitis, choroiditis, neuroretinitis, retinitis albuminurica and 
sudden amaurosis. 

Aside from the sequelae previously spoken of, scarlatina may 
be productive also of chronic purpura, chronic cutaneous affec- 
tions (furunculosis), chorea, paralyses, marasmus and tuber- 
culosis, etc. 

For the differential diagnosis see table, page 327. 

The discussion of the subject in question thus far relates 
principally to cases of scarlatina of ordinary severity. In these 
cases the diagnosis is usually quite easy, and the prognosis, except 
in the presence of serious complications, relatively favorable — 
provided, of course, energetic treatment is instituted early. We 
will now emphasize some of the numerous atypical forms. 

Occasionally scarlatina is associated with an atypical erup- 
tion. Instead of the fine scarlet rash there may be variously 
eruption^ sized papulcs or wheals upon a reddened base ; minute vesicles 
{scarlatina miliar es) ; or pemphigus-like blebs. The exanthema 
sometimes evolves gradually, requiring several days instead of 
hours as is the case in typical scarlatina. The rash may appear 
localized with intervening larger portions of normal skin {scar- 
latina variegata) . Finally, there may be genuine scarlatina, with 
typical angina, nephritis, and even slight desquamation, without 
any exanthema {scarlatina sine exanthema). The diagnosis in all 
e^aShema* such cascs is extremely difficult, and sometimes impossible, 
unless at the same time typical scarlatina prevails in the imme- 
diate surroundings, and the other symptoms point strongly 
toward this disease. 

The course of the attack also may present great variations. 
It may be so very mild and brief as to escape observation, or run 
a mild but protracted course, and remain free from complica- 
tions. In the latter group of cases the temperature may be low, 
or remittent, with evening remissions and morning exacerbations 
(typus inversus). Fever may be entirely absent even in severe 
cases. Sometimes the temperature is very high {hyperpyretic 



SCARLET FEVER. 317 

scarlatina) from the beginning, giving rise to delirium, convul- Nerve- 
sions, etc., but subsides again after a few days, leaving the ^y°^P^°™^- 
patient apparently unharmed. At other times very high tempera- 
ture is characteristic of malignant scarlet fever. 

Scarlatina maligna, gravissima s. fiibninans, fortunately is not Malignant 

. . ^ . . . . . form. 

of very trequent occurrence, in the majority ot instances the 
grave manifestations are in full bloom within the first twenty- 
four hours of the onset of the attack. The child is suddenly 
seized with vomiting, rigors, delirium or convulsions ; the tempera- Profound 

SGDSiS 

ture rises to 106° F. or even higher. The pulse is weak, rapid 
and irregular. Sudden collapse, coma, eclampsia and death 
follow in rapid succession (often within twenty-four hours). 
In another group of cases the course is more protracted, and 
typhoid in character. The temperature is not as high as in the 
aforementioned class, but is marked by evening exacerbations ; 
the tongue is dry, the lips and teeth are covered with sordes, the 
abdomen is very tympanitic, and the stools are watery. The sub- 
maxillary glands are enormously enlarged. There are also signs 
of blood-dissolution, extensive hemorrhages from the nose, gums, ^*^^™gg' 
and stomach, which greatly enhance the (fatal) exhaustion. The 
rash is usually of a violet color and hemorrhagic spots are scat- 
tered over the surface of the body. This form of scarlet fever 
is often spoken of as "septic, hemorrhagic scarlatina." 

Appreciating the unreliability of the initial manifestations, 
the uncertainty in the further symptomatology, the diversity of 
the course of scarlatina and its great tendency toward grave 
complications and sequelae, it is prudent always to be very guarded 
in expressing an opinion as to the outcome of the disease, no 
matter how mild (or serious) the attack. The mortality varies 
in different epidemics, and depends partly upon the age (it is 
high in children under four and over ten years old) of the patient 
and principally upon the number and severity of the complica- 
tions and sequelae. In view of the high mortality it is essential 
to institute prompt prophylactic measures from the very incep- 
tion of an attack of scarlatina. Rest in bed is indispensable even bJd.^ 
in the mildest cases, and should be enforced for at least two 
weeks (much longer in severe cases) from the beginning of 
illness. For about the same len2:th of time should the diet be Restricted 
restricted, avoiding all such articles of food as are apt to upset 
the alimentary canal and to irritate the kidneys. In the active 
stage of the disease the diet should consist of milk only, and, as 



318 COMMUNICABLE DISEASES. 

the symptoms abate, light cereals and thin broths may be added; 
in older children also small quantities of toasted bread and butter, 
fish (boiled), chicken, soft-boiled eggs, and similar light food — 
all free from salt and spices. Easily digestible food should be 
continued for several weeks after subsidence of all traces of the 
disease. These procedures form the most potent means of pre- 
vention of renal and cardiac disease. 

In view of the frequency of ear complications every effort 
nasopharynx, should bc made, firstly, by cleanliness of the nose and throat, 
to prevent infection of the Eustachian tubes, and secondly, infec- 
tion arising, promptly to make a free outlet to the accumulated 
discharge (see Otitis). 
Isolation of As regards isolation, room ventilation, and disinfection, see 

patient. oo 

page 88. 

It is quite difficult to formulate rules for the active treatment 
of the disease. Every case is a law to itself. We have no specific 
to combat the affection. Overdosing — but also underdosing — 
with medicines is to be deprecated. Very mild cases do best if 
left alone, except as regards prophylaxis. 

The average case being usually of medium severity, an attempt 
will here be made to outline a mode of treatment which is best 
suited to meet ordinary indications. The patient should be put to 
bed in a well-ventilated room (about 68° F.), the diet restricted 
to moderate quantities of water and a little milk — in the absence 
of vomiting. As at the onset of the attack vomiting is usually 
very marked, no medication per mouth should be prescribed, 
except, perhaps, a few minute doses of calomel and bicarbonate 
of soda. To relieve high temperature and nervous irritation, we 
Warm baths, order a warm bath every three hours. The baths have also a 
very salutary effect upon the kidneys by enhancing the elimina- 
tion of the scarlatinal poison through the skin. Warm packs may 
be given instead of the baths. As soon as the vomiting has 
ceased, we increase the quantity of nourishment and direct our 
chief attention to the throat. The latter is swabbed every two 
hours with from 5 to 30 per cent, resorcin-alcohol solution or 



with the following: — 



Local 
treatment. 



1$. Acidi carbolici 3ss 

Pulv. camphorse gr. v 

Alcoholis 3ij 

Glycerini q. s. ad 5ij 

M. Sig. : Apply to the diseased parts by means of a cotton swab 
every two hours. 



2 

0.3 
8 
60 



SCARLET FEVER. 319 

The nose should be cleansed with Dobell's solution or similar 
antiseptic. If dysphagia and tonsillar swelling are marked, we 
prescribe moderate doses of sodium salicylate, or one of the newer 
salicylate preparations, and the following mixture : — 

I^ Tinct. ferri chloridi, 

Tinct. myrrhce aa 3ss | 2 

(Kalii chloratis 3ss) | 2 

Glycerini q. s. ad Bij {60 

M. Sig. : 3j every three hours for a child 4 years old. 

^^lth the aforementioned therapeutic measures we are ordi- 
narily successful to favorably proceed with the case up to the 
sixth day, — the time when "scarlatinal diphtheria" is prone to Diphtheria 

. . . , . ., , .. ^,. . antitoxiu. 

appear. As it is almost next to impossible to diiterentiate scar- 
latinal from diphtheritic angina, it is sound and safe practice to 
administer diphtheria antitoxin in all cases of severe angina, 
especially if an exacerbation of the symptoms occurs by the end 
of the first week of the disease. We usually inject 5000 units of 
antitoxin at once and repeat the dose as indications arise. The 
local and internal medicines should be continued, however, except 
bathing, which should be discontinued as soon as the temperature 
comes down to 100° F. The heart's action should be carefully 
watched, and any irregularity or debility detected, promptly 
treated by means of moderate doses of strychnine, digitalis or strychnine 

-^ . . aii<i digitalis. 

strophanthus. The latter two preparations are particularly useful 
in secondary involvement of the heart muscle. With the dietary 
and hygienic precautions taken, one is seldom confronted by 
grave scarlatinal nephritis. Ordinarily the symptoms are limited 
to slight albuminuria with occasional casts and blood-cells, which 
readily disappear upon the administration of a few doses of 
calomel and alkaline diuretics and diaphoretics, high flushing of Enterociysis. 
the bowels and a few hot baths. But, as already suggested, occa- 
sionally the manifestations are extremely violent (delirium, con- 
vulsions, coma, etc.), resisting all sorts of medication, and 
growing worse from hour to hour. In these uremic conditions 
two therapeutic measures have proved to us of particular benefit : -^^^ ^.^^ 
1. Morphine and atropine hypodermatically. 2. Lumbar punc- ^^^ atropine. 
ture. For a child four years old we may administer gr. %o of p^^t^Je 
morphine and %oo of atropine, to be repeated once or twice within 
twenty-four hours. In very bad cases both of these measures 
may be employed simultaneously. Their effect is often magical. 



820 COMMUNICABLE DISEASES. 

Where the uremic symptoms are sHght, bromids with or with- 
Bromids out chloral per mouth or preferably per rectum suffice to reHeve 
the nervous symptoms. As to the management of protracted 
cases of nephritis, see "Nephritis." 

Simple transient scarlatinal myositis calls for no specific 
medication. On the other hand, arthritis demands prompt atten- 
tion, since in the majority of instances it is a manifestation of 
sepsis and if left alone is apt to lead to general pyemia. The 
Salicylates. Salicylates internally and ichthyol externally seem to influence it 
very favorably, and where these measures fail and pus forms we 
should resort to a free incision and drainage — but not too hastily. 
The same holds true for cervical adenitis which, though assuming 
very large dimensions, does not always suppurate. 

For suggestions as to the treatment of the remaining, less 
common complications of scarlatina, the reader is referred to the 
discussion of the respective diseases. 

An extremely difficult problem confronts the attending physi- 
cian when called upon to treat a case of malignant scarlet fever. 
Do what you will, the treatment is seldom of any avail. Early 

Antistrepto- . . . 

coccic and administration of antistreptococcic and antidiphtheritic serums 

antidiph- . . . . 

theritic somctimcs savcs life, and should always be employed, regardless 
of bacteriologic findings in the nasopharyngeal discharges. The 
same holds good for lumbar puncture, if meningeal symptoms 
predominate. High temperatures failing to yield to hot baths 
should be reduced by cold (68° to 70° F.) packs or baths. The 
heart should be kept actively stimulated by strychnine, strophan- 
thus, digitalis, and suprarenal extract, the latter especially in 
hemorrhagic complications. 

During convalescence particular attention should be paid to 
the alimentary tract and skin. The bowels should be looked after, 
and stuffing the child with sweets, heavy meats, and alcoholic 
alcohols' "tonics" Strictly forbidden. The patient should be warmly clad 
and wear flannel or silk next to the skin. Exposure to sudden 
atmospheric changes should be avoided. 

To facilitate desquamation, the child should be given a hot 
soap bath every two or three days followed by oil inunction to 
prevent free distribution of the scales. The following combina- 

Reiieve tiou is quite serviceable, and may be employed also in the erup- 
tive stage of the disease to relieve itching and burning of the 
skin: — 



Duration of 
contagion. 



VARICELLA. ;]21 

R Thymolis gr. x | 0.6 

Acidi carbolici gtt. x | 0.6 

Alcoholis 3ij | 2 

Liq. vaselini Sij | 60 

M. Sig. ; For external use, p. r. n. 

When desquamation is completed and there is otherwise no 
contraindication, the patient may be allowed out of doors. Cod- 
liver oil with the syrup of the iodid of iron and a sojourn at the 
seaside prove very helpful to rapid recovery. 

The patient is "contagious" for at least six weeks from the 
onset of the disease, hence, should not be permitted to mix with 
other children for that length of time or longer, if desquamation 
continues, or discharges from the nose, throat, vagina, etc., are 
present. 

THE FOURTH DISEASEi 
(Duke's Disease). 

The existence of this affection is still awaiting authoritative 
confirmation. Some authorities maintain that it is merely a mild 
form of measles or scarlet fever. It begins after an incubation slight 
period of from 6 to 14 days wnth very mild febrile symptoms 
and an efflorescence on the face, including the circumoral ring. 
The next day the rash spreads, grouped in a sort of lacework 
arrangement, to the extremities and trunk. The course of the 
affection is conspicuous by absence of any severe symptoms Miid course. 
and usually terminates favorably in from 5 to 8 days, without 
any specific medication. 

VARICELLA 

(Chicken-pox). 

The identity of the causal micro-organism of varicella is still 
unknown. It is absolutely proven, however, that it has nothing 

. . Nothing in 

in common with the infectious agent of small-pox ; hence an common with 

. , . small-pox. 

attack of chicken-pox confers no immunity against the former 
affection. The disease is communicable from person to person, 
through an intermediate person, through fomites, and the air. 
Children of from two to ten years of age are especially prone to 
contract the disease, but it is not rarely observed also in very 
young infants, and in children over ten, and even adults are not 
entirely exempt from it. 



efflorescence. 



1 Termed so. being additional to the three known diseases : Scarlatina, 
Rubella and Rubeola. 

21 



322 COMMUNICABLE DISEASES. 

The incubation period lasts about two weeks, the last few 
days showing slight prodromata. Occasionally the symptoms of 
invasion are moderately severe. There may be vomiting, angina, 
conjunctivitis, transient ecthyma, considerable rise of temperature 
preceded by chill, and in small children convulsions. The erup- 
tion, which appears usually in small or large crops without any 
characteristic grouping simultaneously upon several portions of 
the entire body (also the mucous membrane of the mouth and 
throat), is fully estabhshed within twenty-four hours. At first 
vesicular the eruption appears in the form of slightly elevated rose-red 
spots, which disappear on stretching the skin. Within a few 
hours the center of the spot turns vesicular, filled with a clear 
fluid. The spots attain the size of a lentil or pea, but they may 
be larger, pemphigoid, and more rarely umbilicated. On the third 
day the vesicles usually collapse and desiccate, and become 
covered by brownish-black crusts. The latter usually fall off on 
the fifth or sixth day, leaving slight red spots which soon dis- 
severai appear. Repeated recurrences of new crops of the eruption in 

new crops. 

diirerent stages of development (papules, vesicles and crusts), 
sometimes as late as ten to twelve days after the onset, are not 
rare and often serve of signal value in the differentiation of 
varicella from variola, in which latter disease the eruption remains 
uniform and stationary until the final stage of the disease. 
Occasionally the vesicular content is turbid or purulent (usually 
as a result of infection by scratching), and when the pustules 
heal leave behind scars resembling *'small-pox pits." Some- 
times the vesicles burst early and give rise to erosions and 
ulcerations which if occurring in the larynx may be productive 
of attacks of dyspnea and even fatal laryngospasm. The latter 
condition is of very rare occurrence. More frequently we meet, 
usually as a result of infection, wnth multiple ulcerative and 

Gangrene gangrcnous processes of the skin — varicella gangrccnosa — in which 
the vesicles terminate in deep, foul-smelling ulcers, and extensive 
gangrene of the skin. This form of chicken-pox is most common 
in delicate, ill-nourished children and is apt to prove fatal. Com- 

^°°^tions' plications and sequelae in the form of nephritis — nephritis vari- 
cellosa — pneumonia, pleuritis pemphigus — varicella bullosa — 
multiple abscesses, pyemic processes (due to staphylococcic or 
streptococcic infection), icterus catarrhalis, dysentery, polioen- 
cephalitic manifestations, marasmus and even tuberculosis are on 
record, but they are rather of unusual occurrence. 



VARIOLA. 323 

As a rule, varicella pursues a benign and brief course, free 
from high temperature and any other constitutional symptoms, 
and rarely calls for any therapeutic measures. Rest in bed, 
careful diet, and local cooling lotions (2 per cent, thymol) 
or ointments (zinc oxid with 1 per cent, of salicylic acid and 
thymol) to relieve itching usually suffice in ordinary cases. 
Cleanliness of the mouth and throat. Attention to the urine. 
Finally, varicella is occasionally associated with other exan- 
thema {e.g., measles, scarlet fever). For additional differential 
points see table, page 327. 

VARIOLA VERA. VARIOLOID 
(Small-pox). 

The history of small-pox is that of death and destruction. It 
is estimated that, before Tenner's discovery of prophylactic vac- 
cination, one-tenth of all the children died of small-pox. On 
the other hand, with vaccination and revaccination rendered 
obligatory in most of the civilized countries, the occurrence of 
variola in a child is almost unheard of. If it ever does occur in 
successfully vaccinated children, the disease is usually mild, modi- 
fied in form — varioloid. 

Small-pox is an acute, highly contagious and infectious, 
endemic and epidemic disease, characterized principally by an Endemic and 
eruption that passes through the stages of papule, vesicle, pustule 
and scab, — the development of the pustule being accompanied by 
a secondary fever. 

The nature of the small-pox producing poison is still unknown. 
It is undoubtedly a mirco-organism that exists in the eruption and 
probably also in the blood. The disease is most communicable 
during the pustular and desquamative stages — at which time mere 
entering the sick-room is said to infect one not protected by vac- 
cination. 

After an incubation period of from nine to fifteen days, which, 
as a rule, is free from any significant signs of illness, the patient 
is suddenly seized by a violent chill, fever, severe pain in the back, 
convulsions, delirium, prostration, and sometimes collapse and 
death — long before the appearance of the eruption. This mode ^^^ ^ 
of onset and termination is quite common in variola vera, affectino* violent 

^ . symptoms. 

children under three years of age. Some cases survive until 
the appearance of a papular exanthema upon the buccal and 
pharyngeal mucous membranes, and then usually die from 



324 



COMMUNICABLE DISEASES. 




Fig. 83. — Mild Discrete Small-pox in an Unvaccinated Girl. 
Note absence of lesions upon the trunk. (Kindness of Dr. J. F. 
Schamberg.) 



VARIOLA. 



32o 



exhaustion; others again — usually older than three years — suc- 
cumb to the attack in the suppurative stage, or, rather rarely, 
recover after a painful and tedious convalescence. 

It is customary to distinguish three types of variola vera : 
Discrete, confluent, and malignant (hemorrhagic). 

Discrete Form. — After the violent onset, the eruption, con- 
sisting of red, coarse spots, appears during the third day, first on 
the forehead and lips. The constitutional symptoms then abate, 
and the patient feels quite comfortable. On the fifth day of the 
disease the spots develop into papules ; on the sixth day into Papules. 




Fig. 84. — Fatal Small-pox in an Unvaccinated Four-week-old 
Infant. Seventh day of eruption. (Kindness of Dr. J. F. 
Schamberg.) 



vesicles which soon become umbilicated. On the eighth day the 
vesicles are transformed into pustules which emit a characteristic 
odor and on tlie ninth day they become entirely purulent and 
surrounded by a broad red band, the halo or areola, the face 
becoming sw^ollen and the features distorted. On the elcventii 
day it is usually found that pus oozes from the pustules which 
on drying forms the scab or crust. The latter falls off some time 
between the seventeenth to twenty-first day, leaving a red, glisten- 
ing depression or pit which soon changes into a white cicatrix. 
With maturity of the pustules (eighth or ninth day) the symp- 
toms observed at the onset return — secondary fever. This fever 
of suppuration is the most critical period of the disease. In 
favorable cases the secondary fever abates after a few days and 
convalescence follows. The stage of suppuration is very prone 
to be complicated by severe inflammation of the larynx, bronchi. 



Vesicles. 



Pustules. 



Secondary 
fever. 



326 COMMUNICABLE DISEASES. 

lungs, and serous membranes. As further complications or 

sequelae we may mention stomatitis, noma, involvement of the 

eyes (phthisis bulbi), otitis media, dysentery and nephritis. 

Violent Conflucnt Form. — It is characterized by extreme violence 

^°Tionai of the constitutional symptoms and by the confluence of the 

symp oms. gj-^pj-JQj^ ^^ Certain portions of the body, such as the thigh and 

lower portion of the abdomen (Simon s triangle) and the neck. 

Malignant or Hemorrhagic Form. — This type of small-pox 
is characterized by malignancy and irregularity of the symp- 
toms, and coexistence of hemorrhages and petechise. In this form 

Black 

small-pox. are included the so-called black small-pox (variola hemorrhagica 
pustulosa) which usually leads to fatal issue in the suppurative 
stage, and the fulminant type of small-pox (purpura variolosa) 
which ends fatally within from three to. four days. 

In contrast to variola vera with its dreadful consequences 

Varioloid, stauds variola modilicata or varioloid. The latter form of small- 
pox is usually observed in children rendered partially immune by 
previous vaccination or an attack of small-pox. Its course is 
snori shorter and milder than that of the other forms, the eruption is 
slight and devoid of suppuration, — hence its freedom from 
secondary fever and severe complications and sequelae. The mor- 
tality in varioloid varies between 8 per cent, and 10 per cent, in 
infants and about 5 per cent, in older children. 

Small-pox may be confounded, in the initial stage, with menin- 
gitis and, in the eruptive stage, with varicella and morbilli (espe- 
cially morbilli hemorrhagici). Meningitis can readily be elimi- 

Differentiai natcd after a day or two. The differential signs between small- 
diagnosis. -^ . 

pox and the other exanthemata are outlined on next page. (See 

table.) 

If the patient with small-pox is seen early, vaccination should 

Vaccination, ^g performed at once ; it may modify the attack. As a prophylac- 
tic measure it is also advisable to vaccinate all those who come 
and are apt to come in contact with the patient. Isolation, disin- 

Quarantine. fection and preparation of the sick-chamber (the room should be 
kept dark by a deep-red shade) should be carefully carried out, 
in the manner described on page 88. The child should be con- 
fined to bed, and kept on a light but nutritious diet, and liberal 

stimulation, supply of stimulaiits (wine, cognac). Especial attention should 
be paid to disinfection of the mouth and nasopharynx (mild solu- 
tions of potassium permanganate, or chlorate, peroxid of hydro- 
gen). In high temperature and severe nervous phenomena pro- 



TYPHUS ABDOMIXALIS. 



327 







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c >;o-t. 


k" . 








i; o 




:3 <J) 


C3 CO 








C3 U 


T? > 


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328 



COMMUNICABLE DISEASES. 



Warm baths, longed warm baths or cool packs act favorably. To prevent itch- 
ing and extensive pitting we may apply 5 per cent, to 10 per cent, 
ichthyoi. Qf ichthyol in equal parts of zinc and sulphur ointments, covered 
by some unctuous material to exclude the air. It is sometimes 
necessary to tie the patient's hands to prevent scratching; and 
Anodynes. ^^ administer hypnotics and anodynes for the relief of restlessness 
and pain. The child should be quarantined for about six weeks. 

B Antipyrinse salicylatis gr. xxiv ] 1.6 

Tr. cinchonse comp 3iij | 12. 

Syr. aurantii §j | 30. 

Aq. aurantii q. s. ad fSiv | 120. 

M. Sig. : 8ss every six hours for a child 4 years old. (Antipyretic 
and anodyne.) 

I^ Mentholis gr. v 1 0.3 

Bismuthi subgallatis gr. x | 0.6 

Zinci stearatis |ij | 60. 

M. Sig. : Dusting powder to enhance desiccation of eruption and to 
relieve itching. 

TYPHUS ABDOMINALIS 

(Typhoid, Enteric Fever). 

Typhoid fever is an endemic, epidemic, and sporadic infec- 
tious disease due to the bacillus typhosus of Eberth. It is char- 
acterized by a continuous, typical fever, gastrointestinal catarrh, 
in children, and a roscolar eruption. It occurs probably as frequently in 
children (even fetal typhoid is on record!) as in adults, but owing 
to the mildness of the clinical picture it is frequently overlooked. 
The young^er the child the e^reater the deviation of the fever from 

Atypical ^ o o 

course, the usual course. Thus, the onset is either more protracted (with 
symptoms of subacute gastroenteritis) than in the adult or very 
sudden with chills and high fever. In older children the initial 
stage (pyrogenetic stage, first week) resembles that of adults and 
stage, is marked by epistaxis, frontal headache, anorexia, furred tongue 
(later dry and brown), restless sleep, and gradual rise of tem- 
perature. The action of the bowels is not characteristic, and 
constipation may alternate with diarrhea (sometimes bloody). 
The fever reaches its height with the approach of the second 
Fastigium. week (fastigium), and varies in mild cases between 101° and 
103° F. and in severe cases between 104° and 106° F., with 
morning remissions and evening exacerbations (''step curve"). 
Occasionally the typus inversus is observed, and not rarely the 
temperature is remarkably low throughout the entire course of 
the disease. The pulse is sometimes very frequent (160 to 180) 



TYPHUS ABDOMINALIS. 



829 



Diazo- 

reaction. 



but rarely dicrotic. The urine responds to the diazo-reaction, and 
contains traces of albumin. During this stage, the second week, 
the spleen is palpable, but not as distinctly as in adults. The ^^^^e spleen 
roseolar eruption which usually appears about the eighth day on 
the abdomen, chest, back and limbs, is rather scanty and not 
rarely entirely absent. The typical eruption consists of small, 
elevated, rose-colored spots which momentarily disappear on 
pressure. They evolve in successive crops, each crop lasting 



Rose-colored 
spots, in 
crops. 



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Fig. 85. — Fever Curve of Tvphoid Fever in a child 4 years old. 
(Sheffield.) 



about three days, and subside entirely after about ten days. Cor- 
responding to the comparative mildness of the intestinal lesions, 
tympanites, iliac tenderness and gurgling are rarely marked. Apathy. 
During the acme of the fever there are more or less marked 
nervous phenomena. Some patients are drowsy and apathetic; 
some are restless, shriek, and rave; some suffer from defective 
hearing, hyperesthesia, insomnia, or semi-stupor, and, finally, 
others may be dull during the height of the fever but otherwise 
be playful during the entire course of the disease. Children 
almost never present the status typhosus. As a rule, the blood 
gives a positive Widal reaction. (See page 102.) widai test. 

With the beginning of the third week (de fervescent stage) Deferves- 
there is a decided improvement in the general symptoms. The 



330 COMMUNICABLE DISEASES. 

tongue begins to clear at the edges, the appetite (often voracious) 
returns, the temperature declines, as a rule, by lysis, and the 
grave nervous symptoms gradually abate. The temperature 
sometimes drops suddenly and remains normal or even sub- 
normal. In severe cases, however, the fever may continue 

^ ^staga (ambiguous stage) and with it all the other symptoms. Indeed, 
in older children the intestinal manifestations may become more 
pronounced, and hemorrhage from the bowels, perforation and 
peritonitis supervene. The usual bronchial catarrh may extend to 
the bronchioles and pulmonary tissue and lead to diffuse broncho- 
pneumonia. Furthermore, improvement and recovery may be 
Relapse, greatly delayed or entirely arrested by relapses, which are not 
uncommon between the third and fifth weeks, or by the following 
complications and sequelae: Inflammation of the mucous mem- 
branes of the mouth (occasionally noma!), nasopharynx and' 
larynx; parotitis, otitis, cutaneous abscesses, periostitis, peri- 
spondylitis (typhoid spine) ; pericarditis, endocarditis, purulent 

tions and arthritis, pyemia, thrombosis and embolism; paralyses (usually 
neuritis), chorea, aphasia (lasts about a week), dementia, mania- 
cal and melancholy states. The mental sequelae usually consists 
merely of temporary irritability, hypersensitiveness, disposition 
to cry, capriciousness and surliness. On the other hand, cases of 
permanent mental aberration are on record. Typhoid fever is 
sometimes associated with pertussis, morbilli, scarlatina and diph- 
theria and in cases with a predisposition it is apt to be followed 
by pulmonary tuberculosis. Occasionally typhoid is followed by 
a post-typhoidal desquamation of the skin, and during and after 
an attack there is frequently a marked longitudinal growth of 
the bones, especially of the tubular bones of the lower extremi- 
ties. As a result of it, the skin over these bones is transversely 
torn, the tears being indicated at first by red lines, and later by 
white scars. 

The aforementioned grave complications and sequelae are very 
rarely observed in children. As a rule, the prognosis is favorable 
(less so in infants), and, even after severe attacks, convalescence 
comparatively rapid and uneventful. In young children the 
course of the disease is usually very brief, between twelve and 
fifteen days; in older ones it is nearly the same as in adults. 

The morbid anatomical condition in the intestines is much 
Mild intesti- niildcr than in adults; ulcers are rare, and, if present, are small, 

nal lesions. ' '^ 

superficial and isolated ; hence they heal without leaving behind 



TYPHUS ABDOMINALIS. 331 

any cicatrices in the intestines or any tendency to cicatricial 
contraction. 

In view of these marked deviations of the cHnical picture, the 
diagnosis of sporadic cases of typhoid often presents great diffi- Differentia- 
culties. It is apt to be mistaken for simple gastroenteritis — Gastro°°^* 
febrile stage of shorter duration ; spleen, in uncomplicated cases, ^^^^^^ ^^' 
not enlarged ; diazo-reaction and Widal's blood test negative ; 
influenza with pronounced intestinal symptoms — febrile "step" influenza, 
curve absent, nervous phenomena less pronounced, catarrhal 
symptoms more marked, Widal's test negative, the influenza 
bacillus in the expectoration ; pneumonia — more sudden onset, pneumonia, 
more positive pulmonary physical signs, Widal's reaction nega- 
tive, diplococcus pneumoniae in the expectoration, neutrophilic cuiol^^ 
leucocytosis ; acute miliary tuberculosis — irregular temperature 
with sweats, hectic flush, often tuberculous sputum, more pro- 
tracted course, Widal's reaction negative ; tuberculous meningitis meningitis, 
— lower temperature ; slow, irregular pulse and respiration ; 
trough-shaped abdomen ; malaria — usually intermittent or recur- Malaria, and 
rent fever, malarial plasmodium in the blood, influenced by 
quinine ; septic endocarditis — pronounced heart symptoms, chills 
with septic temperature, absence of Widal's reaction. Occasion- 
ally typhoid begins with pain in the occiput, neck and back, 
opisthotonos, and other grave nervous phenomena, presenting the 

,. . , . ^ . . . rT^. .. . . , Cerebro- 

clmical picture oi acute meningitis. Ihe diagnosis m such cases spinai 
is often almost impossible in the first few days of the disease. In 
doubtful cases the bacteriologic examination of the cerebrospinal 
fluid for the diplococcus intracellularis, and of the stools and 
urine for the bacillus typhosus often proves decisive. 

As the contagium of typhoid fever resides principally in the 

... . . . Disinfection 

gastrointestinal contents, it is imperative to thoroughly disinfect of discharges, 
the stools and vomitus, as well as the linen and other articles in 
use that have been soiled by the discharges. Furthermore, by 
taking the precaution of boiling the drinking water or milk, ex- 
cluding mosquitoes and flies from the sick-room, and by avoiding 
dissemination of the source of infection through soiled bath-tubs, 
hands, etc., the disease may be limited to a single patient not- 
withstanding the intercommunication between patient and other 
members of the family. Strict isolation, therefore, is not 
essential. 

Typhoid fever is a self-limited disease and not controllable by 
any specific measures. The treatment, therefore, should be 



332 COMMUNICABLE DISEASES. 

symptomatic, principally hygienic and dietetic. Cleanliness of 
the mouth and nasopharynx, cool sponging of the body, with 
water and alcohol or vinegar, or if the temperature is high, cool 
therapy' P^cks or full baths, at a temperature of from 80° to 90° F., and 
an ice-bag to the head, usually suffice to make the patient fairly 
comfortable. During the first few days we may administer small 
doses of calomel and bismuth, and later dilute hydrochloric acid, 
pineapple juice and some good wine or cognac. Hexamethyl- 
enamine is useful during the entire course of the disease. In 

iiemor?higi! intestinal hemorrhage, an ice coil to the abdomen and opium 
suppository (gr. %o for every year of the child's age) will be 
found very efficient. Rest in bed should be enjoined for at least 
two weeks after defervescence. The diet should be fluid (milk 
with tea or a little cognac, soups, light gruel, chicken broth) 
during the acute course of the disease, and semisolid thereafter, 
^diet. care being taken not to overfeed. Transition to a more solid diet 
should be very gradual. Relapses call for the same mode of 
treatment as the original attack. During convalescence the dif- 
ferent bitter tonics and iron are very desirable, and a sojourn at 
the seashore often works wonders. 

Complications should be carefully guarded against and imme- 
diately treated according to indications. Frequent change of 
position of the patient is usually effective to prevent serious 

of decubitus, pulmonary complications as well as decubitus. The skin should 
be hardened by alcohol, alum-water, etc., and as much as possible 
protected by air-cushions. The slightest abrasion of the skin 
should at once be treated by antiseptic dressings (2 per cent, solu- 
tion of aluminum aceticotartrate). 

Insomnia and excessive restlessness sometimes require 
hypnotics. 

B Olei terebinthinas gtt. xvj | 1 

Olei menthas pip gtt. iv ] 

Mist, acacias q. s. ad Bij j 60 

Ft. emulsum. 

Sig. : 3j every four hours for a child 4 years old. (For tympanites.) 

IJ Tr. nucis vomicae gtt. x^j | 1 

Acidi hydrochlor. dil 3ss j 2 

Aq. aurantii flor q. s. ad .^ij | 60 

M. Sig. : 3j, in water, three times a day for a child 4 years old. 
(Useful as a general tonic during the entire course of illness.) 



ILEOCOLITIS EPIDEMICA. 833 

ILEOCOLITIS EPIDEMICA 
(Dysentery). 

This form of dysentery is entirely distinct from hemorrhagic 
enteritis or proctitis spoken of in connection with gastroenteritis 
on page 203. It is an infectious, epidemic and sometimes spo- 
radic disease caused by the dysentery bacilli described by Shiga, 
Cruse and Flexner. The lesion is localized principally in the Lesion, 
colon and less frequently in the ileum and rectum, and varies 
from a simple inflammation of the mucosa to a croupous, diph- 
theritic inflammation, with a membranous deposit, necrosis and 
ulcer formation. 

In the majority of instances dysentery begins with simple 
diarrhea, without any constitutional symptoms and after from 
twenty-four to forty-eight hours is followed by the characteristic 
symptoms later to be spoken of. In some cases the onset is 
sudden with high fever and, in small children, with convulsions. 
Once the affection is established the symptomatology is quite 
pathognomonic : Colic, tenesmus, and bloody stools. The colic Coiic, 

^ ^^ _ , , -^ diarrhea, 

precedes and accompanies defecation and is followed by severe tenesmus 

r i- J aQ(j bloody 

and prolonged tenesmus. The bowel movements vary between stools, 
ten and thirty or more in twenty-four hours, and the dejecta con- 
sist either of pure blood or of blood and dirty, ragged shreds 
of tissue and fecal masses. The abdomen is most frequently 
sunken, permitting palpation of the contracted colon. The tongue 
is dry and heavily coated, the lips are cracked and covered with 
sordes, the appetite is lost, and the child suffers from intense 
thirst, and occasionally nausea and vomiting. As a rule, the tem- 
perature is raised (intermittent), but it may be normal or sub- 
normal. After a few days the patient becomes greatly emaciated 
and prostrated, very anemic, and the expression of the face Prostration, 
denotes great sufl^ering. Quite a number of children succumb 
during this stage of the disease ; others again continue to battle 
for life and after a course of from seven to ten days begin to 
improve, the stools becoming less bloody and more feculent in 
character, the anorexia less marked, and the general condition 
much better. Relapses are not rare, and, when they occur, there Relapse, 
is a great tendency toward the transition of the acute into a 
chronic process, with a very tedious convalescence, or death chronic 
from exhaustion. ^^^^' 

An attack of dysentery may be complicated by peritonitis. 



334 COMMUNICABLE DISEASES. 

noma, parotitis suppurativa, abscess of the liver, fissura or pro- 
Compiica- lapsus ani, pulmonary affections, etc., and may be followed by 
tions. ij^j-ggj-jj^^l cicatrices and stenosis, paralysis of the sphincters, 
paresis of the extremities, and marasmus. 

The very protracted cases of dysentery are usually found to 

be due to the amoeba coli (entamoeba dysenterise). The dif- 

dysentery. fcreutiation between this form of dysentery, that due to Shiga's 

bacillus, and catarrhal enteritis is important from the therapeutic 

point of view and can readily be made by a bacteriologic 

examination of the dejecta. Furthermore, it is well to remember 

that foreign bodies in the lower bowel may give rise to a group 

of symptoms similar to that of dysentery and that an inflamed 

tion from prolapscd rcctum, intussusception, an ulcerated rectal growth or 

with rectal hemorrhoids with coincident enteritis are very apt to mislead in 

the diagnosis. Careful examination (inspection and palpation) 

of the rectum disposes of these difficulties. 

The patient suffering from dysentery, like one with typhoid. 
Disinfection need uot be strictly isolated. The dejecta and everything coming 
in contact with them, however, should be thoroughly disinfected. 
During an epidemic the drinking water, fruit and vegetables 
should be boiled, all modes of exposure to infection (mosquitoes, 
flies!) avoided. 

Acute dysentery calls for perfect rest in bed, an opiate (pref- 
erably hypodermically or per rectum) for the relief of pain, 
and light astringent diet (tea and toast, rice- and barley-soup or 
Opium, water). In the beginning the bowels should be cleansed with 
one moderate dose of castor-oil or syrupus rhei by mouth and one 
sterile cool water irrigation. The patient is then put on the fol- 
lowing mixture : — 

R. Bismuthi subcarbonatis 3iv | 15 

Vini ipecacuanhae 3j | 4 

Tinct. cinchonae comp .^j | 30 

Mist, acacise q. s. ad f Biij | 90 

M. Sig. : One teaspoon fill every two hours for a child 2 years old. 

Irrigations In severe cases the intestines should be irrigated twice a day 

nitrate of with 1 : 1000 of nitrate of silver, and once a day with 1 : 1000 
quinine.' quinine sulphate solution. The irrigation should be executed 
very gently by means of a soft-rubber catheter attached to an 
ordinary irrigator. Hydropathic applications to the abdomen 
(plain Priessnitz compress, or warm turpentine stupes) are 
useful. 



MEXIXGITIS ACUTA. 



ddo 



Collapse should be combated by local heat, cognac, red wine 
with a hot infusion of cinnamon, camphor, strychnine, etc. 
During convalescence care in dieting is still demanded, and the 
persistent anemia calls for iron, analeptics in the form of strength- 
ening food (fresh eggs, milk with cereals, broths, etc.) and 
plenty of fresh air, and, whenever possible, a sojourn in the 
country, preferably at the seashore. 

Complications and sequelae require special treatment. 

In chronic dysentery the tannates in conjunction with the 
quinine and silver irrigations do better than the bismuth prepara- 
tions. Otherwise the management is the same as in acute dysen- 
tery. The more protracted the course, the greater the exhaustion 
and loss of blood ; and the younger the child, the worse the prog- 
nosis. The mortality in diilerent epidemics varied between 5 per 
cent, and 30 per cent. Early attention is a very great factor in 
reducing the mortality and the tendency toward chronicity. 



stimulation. 



Tannates 
in chronic 
forms. 



MENINGITIS ACUTA 

(Meningitis Cerebrospinalis).i 

MENINGOCOCCIC, PNEUMOCOCCIC, TUBERCULOUS, 
STREPTOCOCCIC, ETC., MENINGITIS. 

Meningitis may be primary or secondary in nature. Primary primary 
meningitis may be the residt of traumatism (may involve both 



1 Our venturesque attempt to disrupt the time-worn, confusmg mode 
of grouping of the different varieties of meningitis is based upon the fol- 
lowing considerations : 1. The sjanptom-complex of fully established men- 
ingeal inflammation is practically identical in all forms of the disease, and 
differs only in the degree of mildness or severity of the attack, which 
depends upon the extent of the lesion, the susceptibility and the power of 
resistance of the patient to the microbic toxin and its baleful effects. 2. 
The same lack of distinction is observed in the pathological anatomy of 
the diverse forms of meningitis, except that in tuberculous meningitis we 
find local or general dissemination of tubercles in addition to the usual 
inflammatory process, which, however, are not manifested by special clin- 
ical symptoms. 3. Even the formerly accepted view as to the characteristic 
distribution of the inflammation in certain varieties of the affection, e.g., 
the so-called "vertical"' or "basilar" meningitis, etc., is no longer scien- 
tifically tenable in a strict sense of the word, since meningitis of the con- 
vexit}- of to-day may, by extension, be that of the base the day following 
and vice versa. With these considerations in view, and appreciating also 
the fact that a positive differential diagnosis of the variety of meningitis 
can be made only by the findings of the etiologic factors in the cerebro- 
spinal fluid obtained by lumbar puncture, we feel fully justified to discard 
tlie time-worn subdivision of meningitis into "serous," "purulent," "'epi- 
demic," "posterior basic," etc., and to classify the disease from an etiologic 
point of view. As we do of "tuberculous meningitis," we speak also of 
meningococcic, pneumococcic, streptococcic, influenzal meningitis, etc. — a 
classification which is not alone scientifically correct, but at once oft'ers a 
clue as to the etiolog}-, mode of treatment and prognosis. 



836 



COMMUNICABLE DISEASES. 



Diplococcus 
meningitidis. 



Secondary. 



Epidemic. 



Sporadic. 



Slow onset 
in tuber- 
culosis. 



Headache, 

projectile 

vomiting and 

convulsions. 



the dura mater — pachymeningitis hemorrhagica — and pia mater, 
but usually the former) or be due to direct infection of the 
meninges by the diplococcus intracellularis meningitidis (Weich- 
selbaum) and other pathogenic bacteria, e.g., streptococci or 
staphylococci. Secondary meningitis is due to extension of the 
infection from neighboring or more remote parts. This form 
includes the tuberculous, or pneumococcus meningitis and the 
meningitides which are met with in divers acute infectious dis- 
eases, such as influenza, typhoid fever, erysipelas, otitis, diph- 
theria and the like. The infection spreads either by continuity 
(throat, nose or ear), by the lymphatics, or by the blood-vessels. 

Meningitis is a disease peculiar to early childhood, the 
majority of cases occurring in the first three years of life. It 
prevails principally, often in epidemic form (cerebrospinal menin- 
gitis), during the late winter and spring months, at a time when, 
with rapid changes in the weather and crowding of the children 
in stuffy rooms, ''colds" and their sequelae are fiercely rampant. It 
is observed also sporadically during all seasons of the year. 
Delicate children are more prone to be attacked than robust ones, 
this being the case especially with tuberculous meningitis, which 
is frequently the culmination of latent tuberculosis of other 
organs of the body. 

The mode of onset of the disease varies greatly. It is usually 
abrupt in primary meningitis, rarely preceded by a few indefinite 
signs of ill health, such as anorexia, restlessness and headache. 
In secondary meningitis the attack, as a rule, develops more 
insidiously and is often obscured by the symptomatology of the 
preceding affection. Meningitis supervening latent tuberculosis 
with few exceptions is particularly prone to be gradual in its 
development. In these cases the child may for weeks manifest 
apathy, anorexia, vomiting, wasting, occasional rise of tempera- 
ture, and other symptoms corresponding to the seat of the original 
lesion {e.g., caseation of the bronchial, mesenteric, or intestinal 
glands; bone or joint disease, etc.). 

Acute meningitis, be it primary or secondary, gives rise to 
dizziness, headache, nausea, projectile and usually persistent 
vomiting, rise of temperature, jactitations up to convulsions, 
alternating with drowsiness, stiffness and pain in the neck. This 
group of symptoms while per se not at all characteristic is never- 
theless strongly suspicious of the disease. Finding a patient in 
this condition we should at once carefully examine him for 



MENINGITIS ACUTA. 



SX 



the following more or less pathognomonic physical signs and 
symptoms of meningitis : — 

Rigidity of the Neck. — This symptom is elicited by placing the 
hand under the patient's occiput and flexing the head upon the Neck 
chest. In meningitis the neck will be found stiff and painful, ^^^p^^^- 
Forcible flexion of the head upon the chest usually produces 
synchronous flexion of the legs upon the abdomen. ^ The child 
instinctively assumes a lateral position, as the dorsal position 



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Fig. 86. — Fever Curve of Tuberculous Meningitis in a child 
2 years old. {Shejfield.) 



proves very painful by pressure of the pillow against the 

head. Rigidity of the neck is present at one time or another in 

all cases of meningitis. It is especially pronounced in cases in 

which the inflammation begins at the posterior part of the brain. 

As the disease advances the rigidity extends to the muscles of the 

back and extremities, giving rise to a spasmodic rigidity of the 

body in which the trunk is arched forward and the shoulders and opisthotonos. 

buttocks are thrown backward while the legs as a rule are flexed 

upon the thighs — opisthotonos. Occasionally the forearms are 

>extended and the fingers clinched in the palms. 

Changes in the Eyes. — Intolerance to light and contraction of Photophobia. 



1 Brudzinski's neck sign. 



neuritis 



338 COMMUNICABLE DISEASES. 

the pupils form early symptoms of meningitis. Dilatation or 
inequality of the pupils is usually met with later. The inequality 
is usually transient and variable, present at one time and absent 
at others ; now one pupil, now the other may be the larger. 
Strabismus and nystagmus are observed in advanced stages of the 
affection. Examination of the fundus reveals in the majority of 
cases of tuberculous meningitis optic neuritis or papillitis, and 
Optic tubercules in the choroid. Optic neuritis is occasionally found 
also in other varieties of meningitis, chiefly when the base is 
involved. After the first week the child often keeps the eyes open 
staring immovably into distance. 

Vasomotor and Cutaneous Disturbances. — Cutaneous irrita- 
tion is usually followed by a vivid and enduring congestion of the 
cerebraies. skin — Taches Cerebrate (Trousseau's sign). This symptom is 
not very significant, being observed also in other infectious dis- 
eases, e.g., typhoid fever. Eruptions of the skin — erythema, 
herpes, urticaria and purpura — are quite frequent. Purpuric 
spots are especially common in fulminant cases (hence often 

Spotted ^ . . ^ 1 r ^ rn^i • 1 

fever, spoken of as spotted fever). Ihey vary m seat and may coalesce 
to form dark diffuse extravasations into the skin. 

Kernig's Sign. — This symptom consists of inability of the 
examiner to extend the patient's legs with the thighs flexed on 
the abdomen. It is met in the majority of cases of meningitis, but 
sign, is not pathognomonic of the disease, since it is observed also in 
other affections, e.g., typhoid fever, and occasionally also in 
normal infants. In conjunction, however, with the other menin- 
geal symptoms Kernig's sign is very helpful in the diagnosis. 

Reflexes. — In the early stages of meningitis the skin and 
tendon reflexes are somewhat exaggerated, but with the gradual 
loss of muscular power they disappear partially or Avholly. 

Babinski's Reflex. — Irritation of the plantar surface of a 
patient suffering from meningitis produces extension of the great 
Babinski's ^^^ ^^^^^ flexiou of the Other toes. It is a characteristic sign of 
sisn. disease of the pyramidal and lateral tracts of the cord, hence is 
more apt to be observed in very diffuse forms of inflammation of 
the meninges and underlying structures (tuberculosis) than in 
the locaHzed forms of the disease. This sign is least reliable in 
infants under two years of age, but is of corroborative value in 
older children. 

Leichtenstern's Symptom. — This consists of lightning-like 
contraction of the whole body on striking any part of the bony 



MENINGITIS ACUTA. 



389 



framework with the percussion hammer. It is a symptom of 
meningitis, principally during the stage of irritation. 

McEzvens Sign. — With the patient in an upright position 
and his head inclined to one side, percussion over the junction of sign.^^^ ^ 
the lower portions of the frontal and parietal bones gives a tym- 
panitic note. This situation corresponds to the anterior horn of 




Fig. 87. — Lumbar Puncture. The patient is put near the edge 
of a table in sitting or lying posture, with the vertebral column 
strongly arched forward. The puncture is made with a thin, hol- 
low exploratory needle in the kmibar region, in the third or fourth 
intervertebral space, at a point corresponding to a line drawn be- 
tween the superior crests of the ilia. {Sheffield.) 



Lumbar 
puncture. 



the ventricle, and the note is caused by the presence of fluid in 
the ventricle. Hence it is most frequently observed in the tuber- 
culous variety of meningitis. This sign is not pathognomonic 
before complete ossification of the skull. 

Mental State. — In the be^einning of the disease the children 
are usually very irritable. They twitch, grind the teeth, start 



stupor. 



340 COMMUNICABLE DISEASES. 

up with a cry of alarm when disturbed, are annoyed by the least 
sound in the room, but as the meningitis progresses, or in the 
tuberculous variety often at its very inception, the patient grad- 
ually enters into a state of apathy, stupor, sopor and coma. The 
experienced clinician in order to arrive at a conclusion rarely 
needs to wait for the synchronous inauguration of all of the 
aforementioned symptoms. Indeed, it is quite uncommon to meet 
with cases which present such an array of typical phenomena. 
One seldom errs in the diagnosis where persistent vomiting, con- 
vulsions, rigidity, photophobia and stupor are grouped together. 
However, the mere diagnosis of meningitis is not sufficient. It 
is also the cause and variety we are interested in. 

Cerebrospinal Fluid. — With the latest improvements in the 
technic of examination of the cerebrospinal fluid obtained by 
lumbar puncture, numerous doubtful points of diagnosis can be 
cleared up which before the introduction of this diagnostic pro- 
cedure forever remained a mystery. 

Normal cerebrospinal fluid is a clear alkaline fluid, containing 
but a small proportion of salines, a small quantity of serum 
globulin, a trace of cholin and a sugar-reducing agent. It is not 
spontaneously coagulable. 

In normal-individuals it escapes through the puncture-needle 
at a low pressure, usually drop by drop. The pressure may 
accurately be measured by the manometer, but the experienced 
eye can well appreciate the amount of tension by observing the 
force of the jet. 

The pressure is usually increased in divers meningeal irrita- 
High tions and is particularly hie^h in tuberculous and hydrocephalic 

pressure. ^ y o ./ ^ i 

conditions. As the stream may be altered hy the position of 
the patient, by the viscocity of the fluid, by interference with the 
flow in its path, etc., the semeiologic importance of pressure is 
rather slight. 

The color of the cerebrospinal fluid may be altered by acci- 
dental or pathological admixture of blood, pus or pigment. In 
acute bacterial meningitis the discoloration varies from sHght 
Clear fluid cloudiness to a well-defined purulent turbidity. In tuberculous 
^^cSosIs' meningitis the fluid is usually clear or slightly opalescent. The 
presence of blood is readily recognized and may be due to acci- 
dental admixture from the puncture wound or to hemorrhagic 
pachymeningitis. 

The bacteriologic examination of the cerebrospinal fluid is of 



Perfect 
technic. 



MENINGITIS ACUTA. lUl 

inestimable clinical value since it often furnishes reliable infor- 
mation, not alone as to early diagnosis, but to prognosis and 
treatment as well. Too much stress cannot be laid upon the fact 
that in order to obtain conclusive pathologic data the examination 
of the fluid should be intrusted to one thoroughly experienced in 
bacteriology and microscopy. Negative results in the majority of 
instances are due to skepticism and faulty technic. Occasionally 
repeated examinations are required. Nearly all kinds of micro- 
organisms have been found. Careful search for the tubercle 
bacillus should be made in all cases of meningitis, regardless of 
clinical data. The finding of the tubercle bacillus in the cere- 
brospinal fluid at a glance settles the diagnosis whereas volumes of bacteria 
descriptions of differential features at best fail. The same applies diagnosis, 
for the diplococcus intracellularis meningitidis, and other patho- 
genic bacteria. 

For the detection of the micro-organism we may use stained 
smears (the specimen having been obtained from the coagulum 
that forms in the fluid on standing or after centrifugation), cul- Cultures, 
tures, or inoculation methods. Where rapid decision is de- 
manded the last two procedures are not adoptable, but as their 
scientific accuracy is incontestable they are not rarely indispen- 
sable in cases of obscure origin and especially in mixed infections. 

Cytodiagnosis is based upon the histological study and deter- 
mination of the number and nature of the formed elements in the 
cerebrospinal fluid. Normally this fluid contains very few cells, 
so few that a smear obtained from the deposit after centrifuga- 
tion only two or three leucocytes may be visible in the micro- 
scopic field. The presence of leucocytes in great numbers con- 
stitutes anatomical evidence of a meningeal lesion, — namely, of 
tuberculous nature, where lymphocytes (mononuclears) prevail, 
and non-tuberculous, where polymorphonuclear leucocytes pre- j.^iJsj^^^' 
dominate. This rule applies only to cases which are neither very 
recent nor very protracted — i.e., to the fully developed acute 
disease — since lymphocytosis is found also in non-tuberculous 
meningitis tending to recovery, in acute syphilitic meningitis, and 
other chronic brain affections ; while polynucleosis is occasionally 
associated with lymphocytosis in chronic tuberculous meningitis. 

Of interest chemically are the facts that in meningitis the 
proportion of chlorides in the cerebrospinal fluid is often reduced 
while that of albumin increased. The albumin consists princi- 



Mononuclears 



342 



COMMUNICABLE DISEASES. 



Serine. 



Differentia- 
tion from 
typhoid; 
apex- 
pneumonia. 



pally of serine, while normally it is mostly globulin. The fibrin 
is increased, while the reducing agent is often absent. 

In the early stages meningitis may be confounded with 
typhoid fever, pneumonia, acute exanthematous diseases, uremia 
and eclampsia from other causes. In typhoid fever the vomiting 
is less persistent, diarrhea the rule, impairment of the sensorium 
less marked and more gradual in development, the spleen 
enlarged, the fever characteristic (step-curve), and the blood 
responding to Widal's reaction. Apex-pneumonia particularly 
may be mistaken for acute meningitis. In pneumonia the "cere- 
bral" symptoms usually clear up with the establishment of the 
signs of pulmonary consolidation, the respiration ratio is increased 
and expiration is prolonged, and the temperature is evenly high. 
On the other hand, in meningitis, the nervous symptoms increase 
with time, respiration is irregular or stertorous and inspiration 
prolonged and sighing, and the temperature variable. The differ- 
entiation between meningitis and a sudden attack of uremia is 
based principally upon the condition of the urine which should 
always be tested in case of doubt. The history also is very help- 
Eciampsia. ful. Eclampsia caused by gastrointestinal intoxication, etc., or 
onset of some febrile disease is apt to be mistaken for cerebral 
convulsions for the first twenty-four hours only — until the alimen- 
tary canal has been cleared, or the other causes of the eclampsia 
have become apparent. 



Uremia. 



Tuberculous Meningitis. 
History : Preceding indisposition. 

Temperature : Low in the begin- 
ning. 

MacEwen's sign : Pronounced. 

Cerebrospinal fluid: Clear; tuber- 
cle bacillus ; lymphocytosis (mono- 
nuclear). 

The eyes : Optic neuritis ; choroid 
tubercles. 

Skin eruptions : Indefinite. 

Paresis : Early. 

Von Pirquet test positive. 



NON-TUBERCULOUS MENINGITIS. 

Apparent good health ; infectious 

disease or otitis. 
High. 

Slight. 

Cloudy or purulent ; no tubercle 
bacilli ; polynucleosis. 

Absent. 

Frequently petechias. 
Late. 

Negative. 



Latent tuberculous meningitis may lead to many errors in the 
diagnosis. It may be confounded with severe remittent fever, 
double otitis media (with or without cerebral abscess), syphilitic 
meningitis, and tumor of the brain. In remittent fever the 
Plasmodium malariae or pigment is readily found in the blood; 
otitis, jn double otitis examination of the ears reveals local lesions and 



Remittent 
fever. 



MENINGITIS ACUTA. ^U^ 

the blood shows marked leucocytosis ; in syphilitic meningitis there syphiiis. 

are other evidences of syphihs (choroiditis, rhagades, spirochsete, 

etc.) ; in tumor of the brain the progress of the disease is slow, 

and there are focal symptoms (localized paralyses, optic neuritis, 

etc.) to account for a local lesion. In doubtful cases lumbar "^°^^- 

puncture and the tuberculin reactions will materially aid in the 

diagnosis. 

The course of meningitis varies greatly not only with the 
cause but with the clinical types of the affection and the severity 
of the epidemic as well. Some cases are mild and transient, 
"abortive"; others are extremely malignant, "fulminant," in 
nature, ending fatally within a day or two, or sooner. The mode 
of commencement offers no certain indication as to the ultimate 
course. As previously mentioned primary meningitis begins more 
suddenly and progresses more rapidly than the secondary variety. 
The great majority of cases are usually ushered in by profuse 
vomiting, rise of temperature, severe headache, pain in the back 
and limbs, sensitiveness of the vertebral column, rigidity and con- 
vulsions. The fontanelles are distended, the bowels confined, the Distended 

fontanelles. 

abdomen is retracted (trough-shaped) and the urine scanty, often 
albuminous. During the early period symptoms of excitement shaped 
of function prevail. The patient is delirious, shrieks (hydro- ^ ^ 
cephalic cry), is very sensitive to noises and light, but very soon cephalic cry. 
he passes into a state of sopor which gradually increases in 
intensity. At a later period of the disease there is depression of 
function. The pulse and respiration which in the beginning are 
accelerated later become irregular and slow, the somnolence Coma, 
deepens to coma, and various paralyses appear. The aforemen- 
tioned eye-symptoms are usually quite marked and involvement involvement 

of cranial 

of the facial nerve pronounced. In disease of the base all parts nerves. 
of the facial nerve may be involved ; in that of the convexity only 
the lower part may suffer. In hopeless cases deglutition also 
becomes affected ; the coma increases, the patient can no longer 
be roused; the coniunctival reflex is abolished, the eyes are Hazy 

•' -^ corneae. 

smeared with mucus or pus ; the cornese are hazy or ulcerated, the 
sphincters are paralyzed; and after lingering in this moribund 
state for another few days the patient is finally relieved of the 
agony by death. Milder, non-tuberculous, cases may gradually 
recover. In this event the disease is usually followed by very 
slow convalescence and frequently by deaf-mutism, aphasia, 
amaurosis, idiocy, etc. Meningitis sometimes runs a protracted 



344 



COMMUNICABLE DISEASES. 



course, continuing for weeks with periods of marked improve- 
chronic nient, but finally ends fatally. These cases generally represent 
course. ^|^^ chrouic fomi of infantile meningitis, which is essentially a 
meningoencephalitis. 

At best the prognosis is very grave. Tuberculous meningitis 
is invariably fatal. The mortality in non-tuberculous meningitis 
ranges between 50 per cent, and 75 per cent. Where operative 
procedures can be brought into use, e.g., traumatic or otic menin- 
gitis with localized lesions, the outcome is more hopeful, provided 
no time is lost and the patient's general health is fair. 

Aside from operative treatment, lumbar puncture for the 
relief of pressure symptoms, and meningococcic antitoxin, little 
need be expected from all other methods of treatment in vogue. 
With the advance in our bacteriologic study of the cerebrospinal 
fluid and the possibility of early detection of the etiologic factor 
of the meningitis in question, there is reason to hope that the 
majority of cases of meningitis will be combated by a curative 
serum. Wonderful results are already on record from the early 
serum, use of antimeningococcic serum in meningitis due to the diplococ- 
cus intracellularis (Weichselbaum). (See page 95.) 

The symptomatic treatment consists of warm baths every three 

IVarm baths. . ^ . . i i -, •, • i ^ , 

or four hours ; ice-bag to the head, bromids and stronger hypnotics 
to relieve excessive irritation; small doses of calomel and large 
lodids. doses of sodium iodid ; careful nursing (feeding by mouth, gavage^ 
or per rectum), and stimulation as necessity arises. Special 
attention should be paid to cleanliness of the mouth and naso- 
pharynx, and avoidance of decubitus. 

When an epidemic prevails all such prophylactic measures 
should be instituted as are recommended for other contagious 

Isolation , . . i- . r 

of patient, and infcctious diseases, especial care being taken to disinfect 
nasopharyngeal discharges. 

I^ Natrii iodidi '. 3ss | 2 

Natrii bromidi 3j j 4 

Aquae menthse pip 5ss | 15 

Aq. destil q. s. ad f 5i j | 60 

M. Sig. : 3j every six hours for a child 3 years old. (Routine treat- 
ment.) 

I^ Hyoscin. hydrobromatis gr. %oo to gr. %oo- 

Sig. : Hypodermically for a child from 3 to 6 years old. (To relieve 
excessive excitation.) 

1 Gavage, or introduction of food directly into the stomach, is per- 
formed in the same manner as lavage (q. v.), except, of course, that the 
fluid is left in the stomach. 



PAROTITIS EPIDEMICA. 



545 



PAROTITIS EPIDEMICA 

(Mumps). 

Primary, idiopathic, epidemic parotitis is a contagious affec- 
tion of tiie glandular substance ( acini and the ducts ) and the 
interstitial tissue of one or both parotid glands. It most fre- 
quently attacks children of from two to twelve years of age, more 
rarely younger and older ones. One attack usually confers 




Fig. 88.— Bilateral Epidemic Mumps. {Sheffield.) 

immunity for life. Secondary or iiictastafic parotitis is not rarely 

met as a complication or sequel of di^'ers infectious diseases So?^from'^" 

and has nothing in common Avith epidemic parotitis. Infection pl^o^i^fs^ 

occurs through the mouth or throat. The specific micro-organism 

is still unknown. 

After an incubation period of from ten to eighteen days and a 
prodromic stage of about forty-eight hours' duration (marked by 
general malaise, pain in the region of the ear and throat), typical 
epidemic parotitis is characterized by a gradually increasing SAvell- Tumefaction. 
ing of the parotid gland in front and below the ear and along 



Testicles. 



346 COMMUNICABLE DISEASES. 

the angle of the lower jaw. The swelling increases up to the 
third or fourth day, remains stationary for another two or three 
days, and then rapidly subsides. Occasionally the glands undergo 
suppuration or chronic induration. Quite frequently after sub- 
siding in one parotid the inflammation passes on to the other; 
more rarely both parotids are involved simultaneously. The 
Involvement ovcrlyiug skiu is usually colorless; more rarely pale red, glisten- 
saiivary ing and painful. The inflammation may extend to the other 
^ ^^ ^' salivary glands, or to the lymph and lacrimal glands, involve the 
tonsils, lids, conjunctiva, and less frequently the testicles, or 
ovaries, vulva or breast — usually on the same side as the 
parotid affected. Occasionally the submaxillary glands alone are 
involved, and, where the parotitis is bilateral and severe, there 
may be a confluence of the bilateral tumors. 

Except pain in swallowing, opening of the mouth, chew- 
ing, turning the head, etc., headache, occasionally vomiting, and 
a rise of temperature during the first or second day of the dis- 
ease, the patient usually suffers no discomfort. Of course, the 
symptoms are materially changed if the testicles (orchitis paro- 
ovaries. tidca) or ovaries, etc., are involved, or if complications make their 
appearance— rather rarely to be observed in cases of ordinary 
severity. Otitis and nephritis form the most frequent compH- 

Complica- . "^ ^, ^ ^ . , , . , . 

tions. cations, i hey may occur during convalescence, less often during 
the acme of the disease. The nephritis is usually hemorrhagic, 
but benign, in nature. The otitis not rarely leads to deafness. 
Other complications of parotitis on record are : Meningitis, 
encephalitis, divers paralyses, psychoses, pericarditis, endocardi- 
tis, arthritis, etc. — the same as are apt to be met in many other 
acute contagious and infectious diseases. Notwithstanding the 
possibiHty of grave complications and sequelae, the prognosis of 
parotitis is almost always favorable, rarely calling for any 
elaborate therapeutic measures. A few days' rest in bed, fluid 
diet, the salicylates for the relief of pain, and local application of 
lead- or potassium-iodide ointment with or without 10 per cent, 
of ichthyol, usually suffice to effect a cure in the majority of 
uncomplicated cases. Complications should be treated according 
Isolation to indications. It is advisable to isolate the patient for about 

of patient. ^ 

three weeks. 

Parotitis may be mistaken for swellings in the same region, 
resulting from stomatitis, alveolar periostitis, retropharyngeal 
abscess, and infected glands from other causes. Bearing in mind 



PERTUSSIS. 347 

the cause, consistency and location of the tumor; the presence or 
absence of an epidemic, and the course and duration of the dis- 
ease, there ought not to be any great difhcuUy in arriving at a 
correct diagnosis. 

The course of secondar}- parotitis differs with its cause. 

PERTUSSIS 

(Tussis Convulsiva, Whooping-cough). 

Whooping-cough is a highly communicable, epidemic and 
sporadic aff"ection, during its height characterized by sudden more 
or less frequent paroxysms of coughing which from time to time 
are interrupted by deep, stridulous inspiration, and followed by a 
period of apparent euphoria of variable duration. The specific 
germ of the disease is still unknown. As a rule, the course of 
pertussis is divisible in three distinct stages : Stadium catarrhale, 
convulsivum, and decrementi. 

The stadium catarrhale, which lasts about ten days, begins 
after an incubation period of from five to nineteen days. It is 
sometimes preceded by a few indefinite prodromata, consisting 
of loss of appetite, languor, restless sleep, and slight fever, and 
as these symptoms gradually disappear they become replaced by 
those of a simple catarrh of the upper air-passages, so that the 
advent of the grip or measles is often suspected. At first the 
cough is short, hacking, sometimes croupy in character, but short, 
steadily it grows worse, though returning at longer intervals. It cough, 
is especially troublesome at night, and what, as a rule, is partic- 
ularly characteristic of the w^hooping-cough, the cough fails to 
respond to the remedies usually efficient in ordinary ''coughs and 
colds." Toward the end of the catarrhal stage the child is off 
and on attacked by a paroxysmal cough, thus indicating the early 
advent of the second, convulsive stage of the affection. 

The stadium convulsivum may last from two to four weeks paroxysmal 
or, if left to run at random, as many months. The cough is ^^^^^' 
violent and explosive, each paroxysm being often preceded by a violent, 
slight aura, by vomiting, sneezing, etc., so that older children are cough.^^^ 
usually aware of its approach. 

Children able to walk usually run toward a person or object 
to support themselves during the attack, and infants manifest the 
approach of the paroxysm by a sudden outburst of crying. Each 
paroxysm, which lasts from a half to five minutes, consists of a 
number of short, barking, expiratory acts of coughing, from time 



Catarrhal 
stage. 



348 



COMMUNICABLE DISEASES. 



Whoop. 



Venous 
stasis. 



Convulsions. 



Declining 
stage. 



to time interrupted by deep whistling or stridulous inspirations — 
which constitute the "crow" or "whoop" — and is ordinarily (may 
be followed by a second or third fit of coughing) concluded with 
the expulsion of glassy, tenacious mucus and often also by vomit- 
ing of food residue. During a paroxysm the face is at first red, 
then cyanosed, and the veins in the neck swell. As the attacks 
grow worse, there is considerable venous stasis, puffiness of the 
face (which remains occasionally permanent), especially at the 
eyelids ; there is bleeding from the nose and throat, in the skin, 
conjunctiva, more rarely from the ear (rupture of the drum- 
membrane, which heals spontaneously), in the meninges (cause 
of convulsions), etc. In delicate and young children a paroxysm 
is not rarely associated with involuntary defecation and urination, 
and at times also general convulsions. The number of paroxysms 
varies between ten and sixty in twenty-four hours. They are 
more frequent with the patient living in unhygienic surroundings, 
after overloading of the stomach, on excitement from any cause 
(crying, laughing, etc.), irritation of the nasopharynx and larynx 
(often a useful means of diagnosis!). In mild and moderately 
severe cases the child is apparently quite well between the attacks ; 
in very severe cases, however, the patient is weak, pale, emaciated 
and sufifering from troublesome bronchitis and often from a 
number of other grave complications soon to be related. Under 
proper treatment the paroxysms in uncomplicated cases are, as a 
rule, more or less checked after from ten to twenty days. The 
paroxysmal stage is then followed by the regressive stage, stadium 
decrementi. The attacks become less frequent, they lose their 
typical character, the cough returns to the original catarrhal type 
and finally abates entirely. This declining stage ordinarily lasts 
for from two to three weeks. Occasionally, however, especially 
in cases exposed to unsanitary conditions and careless treatment, 
this stage may continue for months and be interrupted by relapses 
which often undermine the patient's constitution and lead to irre- 
parable lesions in different organs of the body. 

Divers complications and sequelae have been noted : Of the 
lungs: Capillary bronchitis, bronchopneumonia, emphysema, and 
phthisis, and acute miliary tuberculosis (as a 
result of caseation of the bronchial glands) ; of the heart: dila- 
tation, pericarditis and myocarditis; of the brain: divers par- 
alyses (hemiplegia, facial, laryngeal, etc.), hemorrhagic, or tuber- 
culous meningitis, encephalitis, softening of the brain, mental 



Grave 

'""^Sont bronchiectasis 



Heart- 



PERTUSSIS. 349 

affections, such as imbecility, idiocy, and dift"erent forms of 
insanity; of the spinal cord: myelitis, poliomyelitis, hemorrhagic 
inflammations, and polyneuritis; of the ears: otitides, with or 
without permanent deafness; of the eyes: amblyopia, amaurosis; 
also nephritis, sublingual ulceration (as a result of friction of the 
sublingual parts against the teeth during a paroxysm), severe 
epistaxis, and emphysema cutis from rupture of some pulmonary 
alveoli. Delicate, especially bottle-fed babies not rarely suffer 
from gastroenteritis with subsequent marasmus, and, finally, 
sudden collapse from respiratory and heart-failure may ensue at faifure. 
the acme of a protracted fit of coughing. 

Fortunately the cases are not all of so grave a nature and so 
dreadful in their consequences. Numerous abortive cases are on 
record in which the second stage is devoid of the "whoop" Miid form, 
(sometimes replaced by attacks of sneezing), and the third is of 
very brief duration, so that in the absence of an epidemic or a 
definite source of infection there is justification for a doubtful 
diagnosis. When the whoop is absent some assistance in the ^^ 

_ ^ _ _ ^ _ Character- 

diagnosis mav be obtained bv a careful examination of the blood, if-ic blood 

* - ^ changes. 

which will show that during the second stage the polynuclear 
cells are increased twice in number, and the lymphocytes about 
four times. Of diagnostic importance also is the fact that the 
urine has a high specific gravity (1022 to 1032) and contains an 
excessive amount of uric acid crystals. The diagnosis is often 
almost impossible during the first stage of the aft'ection, especially 
if following — which is quite frequently the case — measles, and 
time alone is the only reliable guide. 

No other communicable affection of childhood is as lightly gl^lrany 
regarded by the laity and as carelessly treated by the physician estimated 
as that under discussion. Notwithstanding the facts that it pre- 
vails during the greater part of the year ; that its mortality ranges 
between 4 per cent, and 6 per cent, as an immediate result of the 
disease, and at least as high as 10 per cent, in consequence of 
complications and sequelae — thus demanding a greater proportion 
of victims than typhoid and pneumonia combined — no strenuous 
effort is being made to still its ravages, to arrest its- spread, or to 
abort its course. The fallacious impression has gained firm 
ground that whooping-cough "must run its course of from six to 
eighteen weeks," and even the scientific, practical physician wisely 
nods his head in affirmation and despair, lest he be ridiculed by 
the therapeutic nihilist. One has to be bold to venture to claim 



350 



COMMUNICABLE DISEASES. 



success in allaying the spasm, reducing the number of paroxysms, 
Prompt and preventing the dreadful compHcations of the disease, and the 
very^iS™f1fL One who dares to proclaim the possibility of cutting short the 
lengthy course courts everlasting infamy! All the same, the 
severest attack of whooping-cough properly treated may be ren- 
dered almost innocuous, or at least free from grave consequences. 
As soon as the diagnosis has been established with any fair 
degree of certainty (even earlier where direct infection is demon- 
strable), the patient should be isolated, and the expectoration dis- 
infected. For the latter purpose a sputum cup is very helpful. 
Isolation should be practised principally during the expectorating 
period — at least three weeks. 
Fresh air. Fresh air being one of the most essential and efficient thera- 

peutic measures, the child should be kept outdoors the greater 
part of the day (except in the presence of grave complications), 
and the rooms constantly aired with the patient indoors. When- 
ever possible, two or more rooms should be made use of. The 
food should be bland and strengthening, and given in small 
amounts preferably after the paroxysms. The clothing should 
correspond with the season of the year. It is true we possess no 
ideal specific cure against the disease, but a great deal can be done 
to lessen the number and severity of the paroxysms and to 
prevent complications by resorting to the following medicinal 
agents : — 

IJ Olei eucalypti 3iv [ 15 

Tinct. benzoini comp q. s. ad f§ij j 60 

Quinine. ]^ gig . 3j [^ ^ pjj^^ of j^q^ water, to be used for inhalation through 

a croup kettle three times a day. 

B Quinine ethyl carbonate,! or diquinine carbonic ester2. . 3ss | 2 

Syr. simplicis q. s. ad f Bi j | 60 

M. Sig. : 3j every two to four hours, according to the severity of the 
paroxysms, for a child 3 years old. 

Whenever necessary a small dose of some morphine prepara- 
tion with or without 2 grains of antipyrine may be administered 
Antipyrine. |-q inducc rcst or slccp, and, where the heart is weak, a fresh 
infusion of digitalis will prove a grateful addition. Numerous 
other proprietary remedies have been found serviceable, but cau- 
tion is commended in their promiscuous use. 

The paroxysms may frequently be controlled by pulling the 
lower jaw downward and forward. This manipulation is harm- 

1 Euquinin. ~ Aristochin. Because of their tastelessness these prepara- 
tions are to be preferred to ordinary, bitter, quinine. 



TUBERCULOSIS. 351 

less and painless. Its application is contraindicated only in the 
presence of food in the mouth or esophagus. 

Chloroform anesthesia will sometimes relieve the paroxysms chloroform, 
almost magically, and should be tried in desperate cases, especially 
in those associated with convulsive seizures. 

Complications and sequelae arising should be treated according 

to indications. Antispas- 

modics. 

IJ Ext. belladonnse fl gtt. iv _ 0.25 

Vini ipecacuanhse gtt. xvj 1 

Natrii bromidi gr. viij 0.5 

Syr. amygdal q. s. ad Bij 60 

M. Sig. : 3j every two to four hours for a child 2 years old. 

R. Creosoti carbonatis . .'. ., 3iv ] 15 

Sig. : Gtt. ij in a teaspoonful of sweetened water every three hours 
for a child 3 years old. 

TUBERCULOSIS. 
INTRODUCTORY REMARKS. 

Without denying the possibility of ante-natal direct bacillary 
transmission of tuberculous disease from parents to offspring, it 
may be set down as absolutely certain that, with but very few 
exceptions, tuberculosis in infancy and childhood, as in adoles- Acquired 

• • 1 , r , • r • 1 1 11 affection, 

cence, is acquired as a result of post-natal infection by the tubercle by inhalation 

and Ingestion 

bacillus of Koch. The bacillus invades the human organism of tubercle 

. bacillus. 

principally through the respiratory (by inhalation) and alimen- 
tary (by ingestion) tracts, and less frequently through the skin 
or mucous membranes (slight traumatism, skin eruption, etc.). 

The readiness with which infection occurs depends chiefly 
upon the power of resistance of the patient and the environment 
in which the patient is forced to live. This explains the greater 
frequency of tuberculous disease in children of tuberculous undermined 

^ •' , . . constitution. 

parentage. An undermined constitution from one cause or 
another forms an easy prey to the tuberculous germ and, varying 
with the primary seat of infection, the natural recuperative 
strength of the tissues involved and the therapeutic measures 
adopted to resist and combat further systemic invasion, tuber- 
culous disease may remain localized or become general, and 
pursue an acute or chronic course. 

The successful management of tuberculosis rests upon a 
thorough appreciation of the aforementioned facts. We possess 
no specific remedy against tuberculosis, once fully established, but 
the disease is certainly preventable and in its incipient stage 



352 



COMMUNICABLE DISEASES. 



Prophylaxis. 



curable — a great deal more than can be said of a number of non- 
tuberculous, organic affections. 

Prevention of tuberculosis in a child must begin immediately 
after its birth. The air the infant is to breathe should be 
pure, the room it is kept in sanitary and well ventilated, 
though warm enough to suit its needs. From earliest infancy 
the child should be gradually accustomed to outdoor air, and, 
as it grows older, it should spend most of the day outdoors, 
except when the weather is particularly bad. In this event it 




Fig. 89. — Tubercle Bacilli and Micrococcus Tetragenus (spu- 
tum). Gabbet's stain, Leitz ocular I, oil immersion %2. («) 
tubercle bacilli; (b) micrococcus tetragenus. {Lenliavtz and 
Brooks.) 



should remain well dressed in front of an open window. Especial 
Outdoor air ^.ttcution should be paid to its breathing. Any obstruction to 
free nasal breathing, be it adenoids, hypertrophy of the tonsils or 
of the nasal mucous membrane or deformity of the nasal bones, 
should be treated or removed without delay. The child should 
be taught to breathe deeply — few children know how to breathe, 
as is readily evinced in examining a child's chest. Infants should 
Free be encouraged to cry off and on, and older children to recite and 

breathing. . 

sing in the open air. As the child grows old enough intelligentl}^ 
to follow instructions, it should be taught the following breathing 
exercises : — 

1. Deep inhalation, while raising the arms to a horizontal 
position; slow exhalation, bringing the arms down. (See Fig. 90.) 

2. Deep inhalation with the arms placed lightly upon the 



TUBERCULOSIS. 



353 



front of lower portion of chest; slow exhalation, bringing the 
arms down. (See Fig. 91.) 

3. Deep inhalation, while bringing the arms first to horizontal 
postion then above the head, and lastly — while still holding the 
breath — bending the upper body backward; slow exhalation, 



while lowering arms sideways. 

Fig-. 90 



(See Fig. 92.) 

Fig. 91 



Fig. 92 






Fig. 94 




Breathing 
exercises. 



Figs. 90 to 94. — Breathing Exercises. (Sheffield.) 



4. Deep inhalation, while bringing the hands together in front 
of abdomen, and from here slowly along the thorax and chin 
above the head and as far as possible in back of it ; slow exhala- 
tion, bringing the hands clown to original position. (See Fig. 93.) 

5. Deep inhalation, while bending the upper body as far back 
as possible, with the hands fixed on the hips ; slow exhalation, 
while resuming original position. (See Fig. 94.) 

During the breathing exercises the child assumes the position 
of military ''attention." He breathes with the mouth closed, 
occupying about four seconds for inhalation, four seconds for 

23 



Mouth 
closed. 



354 COMMUNICABLE DISEASES. 

retention of the air and three seconds for exhalation. The exer- 
cises should be practised either outdoors or in front of an open 
window, at first four or five times a day, but, after the child gets 
accustomed to properly expand his chest during the respiratory 
Moderation, act, only oucc or twice a day or not at all. The breathing exer- 
cises, like any other physical work, should not be overdone, and 
never continued so long as to become tiring. As prolonged hold- 
ing of the breath interferes with the normal heart's action, it is 
contraindicated in organic heart disease. Short-distance run- 
ning, and peaceful outdoor games (handball, basketball, and 
tennis) also are helpful to expand the lungs. The principal 
benefit derived from these breathing exercises is the purification 
of the lung tissue by the free inflow and uniform distribution of 
oxygen, thus preventing pulmonary congestion which acts as a 
predisposing cause of tuberculous infection. 

What pure air does for the prevention of pulmonary tuber- 
culosis, suitable feeding from birth will do for the prevention of 
nutrition, tubcrculosis of the alimentary tract. It is highly essential ever 
to bear in mind that tubercle bacilh rarely, if ever, survive the 
action of normal digestive juices. The gastroenteric tract, espe- 
cially the stomach, therefore, should be spared pathologic altera- 
tion. Breast milk of a healthy mother or wet-nurse should at 
all times be the food of choice for an infant up to nine months 
old. With increasing age the dietary should undergo gradual 
changes, always selecting, however, such articles of food as will 
best accomplish the object in view, i.e., ample nutrition for the 
growth and development of the child with least possible injury to 
the digestive organs. Overfeeding especially is to be avoided. It 
goes without saying that contaminated food should never form a 
Germ-free P^^^ ^^ ^^^ dietary. Cows' milk of doubtful purity should be 
cows' milk, sterilized, and other articles of food of such character boiled. 
The teeth should receive especial attention, as cavities of decayed 
teeth not rarely harbor tubercle bacilli and early loss of the 
permanent teeth forms one of the principal causes of acute and 
chronic dyspepsia — as a result of insufficient mastication of the 
food — and indirectly enhances the development of tuberculosis. 
Children should be taught to eat slowly, and to refrain from eat- 
ing between meals. For further details as to mode of feeding, 
see page 60. 

Tuberculous infection through the skin and contiguous mucous 
membranes should be guarded against by scrupulous cleanliness 



TUBERCL'LOSIS. 355 

of these structures, avoidance of external injury and skin erup- 
tions, and by immediate treatment of open wounds and all such 
skin lesions as are associated with itching and compel scratching. 
Those intrusted with the care of babies and older children should 
be instructed to give their charges a tub bath (see page 83) in 
the evening and a sponge bath in the morning followed by gentle 
rubbing of the entire body. Of course, the bathing should include 
careful cleansing of the nails, which should be kept clipped short; 
of the ears, of the nose and scalp, and. in older children, also of 
the teeth. From earliest infancy children should very gradually 
get accustomed to cool sponge baths. These are very bene- 
ficial to counteract the susceptibility to frequent colds. At first 
the infant may be given a cool alcohol sponge, and after tolera- 
tion has been established the alcohol should gradually be replaced 
by water, and finally by full cool tub- or shower-baths. The 
advisability of cleansing the infant's mouth is still a matter of 
great diflierence of opinion. I am inclined to favor gentle z^'ipiiig 
of the infant's mouth twice daily with a cotton swab dipped in 
sterile water. Older children should be taught the use of a soft 
brush for the teeth and an antiseptic gargle for the mouth and 
throat. The importance of early removal of nasopharyngeal ^^l^vnx^*^" 
obstruction to breathing has already been alluded to. This ques- 
tion cannot too strongly be emphasized, for the adenoid tissue in 
addition to interfering with free respiration is surely one of the 
most rampant sources of tuberculous infection. Skin eruptions 
should at once be combated. This refers especially to running 
sores from whatever cause, and to all skin diseases which 
sooner or later lead to maceration and denudation of the skin. ^pen^^-oSnds 
Intertrigo in infants is best prevented by frequent changing of the 
diapers and keeping the buttocks perfectly clean and dry. The 
child should be kept from scratching the afi'ected portions of the 
skin by immediate application of antipruritic drugs and by 
restraining the child's hands by means of one of the many useful 
contrivances. Open wounds should be dressed antiseptically 
until healed. \'accination wounds especially should receive care- 
ful attention. Certain though it be that latent tuberculosis is 
occasionally lighted up through vaccination, and that tuber- 
culosis has in very exceptional instances been traced to vaccine 
infected by tubercle bacilli, it is absolutely settled that the great 
majority of cases of tuberculosis following vaccination are the 
result of direct bacillary infection through an unprotected vacci- 
nation wound. 



Care of 

vaccination 

wound. 



356 



COMMUNICABLE DISEASES. 



Effective as these local measures are in the prevention of 
tuberculosis, their efficiency is very insignificant as compared 
with the natural defensive resources of a healthy constitution. 
Our aim, therefore, should be directed chiefly, from earliest 
Fostering infancy, to render the patient, so to say, immune against tuber- 
culosis. This is best accomplished by outdoor life, wholesome 
nutrition, and sanitary environment. Those showing a tendency 
to remain delicate in health should reside in the country. 

a 



immunity. 






w 



Fig. 95. — Acute Pulmonary Miliary Tuberculosis (Cut Sur- 
face of the Lung), (a) So-called obsolete tubercle (old encap- 
sulated caseous focus. (b) Induration. (r) Caseous, partly 
agminated nodules (transverse section of caseous bronchi), (d) 
Submiliary non-caseated tubercle in the true lung tissue. (e) 
Tubercle of the pulmonary pleura. One-half natural size. 
(Langerhans.) 

MILIARY TUBERCULOSIS 
(Hasty Consumption). 

Wide dis- This discase is characterized by wide distribution of the 

tribution of . rr^, i r • i i i -n ^ 

lesions, tubcrculous Icsioiis. The latter are from a pmhead to millet- 



TUBERCULOSIS. 



6b/ 



seed in size, gray or yellow in color, and firm in consistence. 
They are found scattered throughout almost all organs and 
tissues of the body, but especially the lungs and bronchial glands, 
intestines and mesenteric glands, the liver, spleen, kidneys and 
bladder, and the brain and its coverings. They may remain 
latent for some time, or give rise to indefinite symptoms, such as 
anorexia, dyspepsia, gastroenteritis, and emaciation, or symptoms 
of pulmonary phthisis. The outbreak is often determined by 



Latent 
course. 




Fig. 96. — Miliary Tuberculosis (skiagram). (Sheffield.) 



some intercurrent disease or traumatism, but once established it 
usually runs a very violent course. 

The temperature rises, is intermittent, hectic in character. Hectic fever. 
only rarely drops to normal, and may be associated with chills 
and sweats. In the beginning, especially in the absence of marked 
pulmonary symptoms, and in the presence of large liver or spleen 
or both, the disease greatly resembles malarial fever or typhoid. 
Careful examination, how^ever, reveals the absence of the malarial 
or typhoidal germs in the blood. Where signs of pulmonary dis- 
ease predominate, it is readily confounded with lobar or lobular 
pneumonia. In such cases the diagnosis is extremely difficult 
and often can be decided only by microscopic examination of the 



Resemblance 
to malaria, 
typhoid and 
pneumonia. 



358 COMMUNICABLE DISEASES. 

sputum (frequently negative) and the tuberculin test. As the 
disease advances the diagnosis may be based upon the extreme 
emaciation, multifariousness of the symptomatology, and the 
violence and persistence of the febrile attacks. 

The symptoms and course of the disease differ with the seat 
Pulmonary, of the Icsious. The luugs aluiost invariably show signs of con- 
and^'ceTebrai solidatiou (dulluess. Crepitant rales, dyspnea, cyanosis, short 
symp oms. ^.^^g]^^^ ^^^ ^^^ intcstiucs rarely escape involvement. In some 
cases brain symptoms (apathy, jactitations, stupor, localized con- 
vulsions, tubercles in the choroid, etc., up to a typical picture of 
meningitis) predominate; in others again symptoms of disturbed 
circulation (marked cyanosis, edema, rapid feeble pulse, anemia 
and exhaustion, etc.) prevail. The latter phenomena usually 
precede the fatal issue, which generally occurs within from four 
to eight weeks. Cases running a subacute course may last a few 
weeks or months longer, are not rarely erroneously diagnosticated 
and treated as marasmus, their true nature not being^ detected 

Differentia- ., ,. . . , -,11, 

tion from until post mortcm. it is m those cases, particularly, that the 

marasmus. . ,,-,.,,. 

von rirquet or Lalmette reactions are so heipiul m the diagnosis, 
and should always be resorted to early. For then and then only 
may our efforts to arrest or possibly cure the disease prove 
successful. 

For details of treatment see page 363. 

PHTHISIS PULMONUM 
(Tuberculosis of the Lungs and Bronchial Glands). 

The lungs proper, the bronchial glands, or both, may be the 
primary seat of tuberculous deposits. The upper lobes are more 
frequently affected than the lower, and the portions adjacent to 
the bronchial glands more so than the remaining parts. The 
^^chan^es^ pathologic cliaugcs cousist essentially in the formation of vari- 
ously sized caseous nodules filled with colonies of tubercle bacilli 
and large, so-called giant cells, and subsequent softening and 
breaking down of the nodules, forming cavities which may vary in 
size from a pea to a walnut or larger. In some cases, especially 
in those receiving early and suitable treatment, the tuberculous 
process is arrested by encapsulation of the necrosed structures by 
newly formed connective tissue, leading to contraction and forma- 
tion of a firm cicatrix. In this event the enclosed caseous masses 
are in part absorbed, and in part calcified. 

The tuberculous affection of the bronchial glands also consists 



TUBERCULOSIS. 



359 




Fig. 97. — Tuberculosis. Horizontal sec- 
tion through the tuberculous lower lobe of 
the right lung of a two-year-old child, (a) 
caseous focus in the region of the anterior 
border; (b) non-tuberculous posterior bor- 
der; (c) transverse section of bronchus; 
(d,d'^) caseated lymph glands; (e) pul- 
monary vein ; (/) point of adhesion of the 
^ein e with the lymph gland rfi ; (g) 
tubercle in the lymph vessels of the lun 
parenchyma; (h) periarterial, (i) peri- 
bronchial, (k) perivenous tubercles; (/) 
lymph-vessel tubercles of the pleura; (in) 
tubercle in the connective tissue of the hilus 
of the lung. X 3. (Ziegler.) 



360 . COMMUNICABLE DISEASES. 

Hyperplasia in hyperplasia and caseous degeneration. This process usually 
glands, (sooner or later) extends to the contiguous structures, exerts 
pressure upon the adjacent blood-vessels, nerves, and bronchi, 
and, after forming adhesions, may displace, erode and perforate 
these parts. In this manner not only may tuberculous infection 
be rapidly carried throughout the lungs and more distant organs 
(producing an acute or chronic tuberculous pneumonia), but per- 
foration of a blood-vessel or bronchus or entrance of caseous 
masses into the trachea may unexpectedly produce sudden and 
often fatal hemorrhage or suffocation. 

The symptoms vary with the primary seat of the lesion and 
the subsequent pathologic changes. A small tuberculous focus,. 
be it in the lung or bronchial glands, rarely gives rise to any 
definite clinical phenomena. As a rule, in the beginning the dis- 
ease pursues a latent course. This is especially true in infants. 
The child is pale, loses in weight, often notwithstanding good 

Emaciation, appetite ; gets tired on slightest exertion, "hems" and coughs a 
little, and the temperature rises somewhat in the evening. Sooner 
or later the symptoms become more distinct. Emaciation, cough, 
and gastrointestinal disturbances increase in severity, the child 
suffers from dyspnea, and, if the bronchial glands are involved, 

Paroxysmal ^^^^^ paroxysmal attacks of cough, greatly resembling per- 
tussis. This cough is the result of pressure exerted by the 
enlarged bronchial glands upon the pneumogastric and recurrens 
nerves. Physical signs, however, are often still wanting. Occa- 
sionally percussion over the mediastinum may reveal increased 
dullness, but in infants this symptom is not pathognomonic in 
view of the physiologically large thymus. Indeed, the disease is 
often not detected until grave, not rarely fatal, symptoms (e.g.^ 
Diagnosis hemoptysis, hectic fever) announce the seriousness of the condi- 
^^^ entire tion. The diagnosis of pulmonary phthisis in infants, therefore, 
picture, must be based upon the entire clinical picture, rather than the 
local symptoms. If, for example, bronchial catarrh is associated 
with progressive emaciation, multiple glandular swellings, pro- 
tracted diarrhea and possibly also some bone or joint disease, the 
diagnosis of tuberculosis is justifiable even though careful 
examination of the thorax fails to disclose pulmonary consolida- 
tion or cavity. For corroborative evidence we should carefully 

Tuberculous examine the child's sputum (obtained by means of a catheter 
introduced to the base of the tongue) for tubercle bacilli, and 
employ the tuberculin test. 



TUBERCULOSIS. 



361 



In older children the symptomatology of pulmonary tuber- 
culosis is essentially the same as in adults. Its onset is usually 
insidious, and quite frequently follows delayed convalescence from 
some acute disease, such as pertussis, morbilli, broncho- or lobar 
pneumonia and the like. The child fails fully to recuperate, is 
pale, thin, and feeble ; suffers from slight shortness of breath, dry 
cough, chilliness and fever. At first these symptoms are more or 
less masked, but as the lung destruction advances the symptoms 
and physical signs rapidly grow worse. The cough becomes 
persistent, often distressing, especially at night, and attended by 
expectoration and pain. The fever is intermittent or remittent 
(hectic) in character. It is usually normal or slightly above nor- 
mal in the morning, and from two to three degrees higher in the 
evening. It is often preceded by chilliness and followed by pro- 
fuse sweating. During the height of the fever the cheeks are 
usually brightly flushed and contrast strongly with the remaining 
portions of the face, which are deathly pale. Night-sweats are 
often observed early in the course of the disease. With further 
progress of the disease, the expectoration becomes mucopurulent 
or purulent, mummular, and streaked with blood; the fever more 
irregular, and attended by great exhaustion, and the emaciation 
profound. 

The agony may further be aggravated by the concurrence of 
a number of painful complications. The disease may extend to 
the pleura (pleuritis sicca or with serous or hemorrhagic effu- 
sion) ; to the trachea and larynx (dysphagia, frequent hemor- 
rhages, and aphonia) ; to the alimentary tract (colHquative 
diarrhea) ; and where the bronchial glands or pleura are involved, 
to the pericardium (pericarditis). By this time and sometimes 
at an earlier period the child presents a characteristic, ghastly 
appearance. The cheeks are hollow, the eyes and temples sunken, 
the bones of the face and the ears prominent, the nose is pointed 
and drawn, and the hair thinned, lusterless and brittle. The face 
is either deathly pale or marked by florid redness along the 
zygomatic regions. The neck is wasted, the supra- and sub- 
clavicular spaces are depressed, the shoulders stoop, and the 
shoulder blades project wing-like far beyond the shrunken, im- 
movable spine. The thorax is narrow and contracted, and the 
ribs overlap each other, effacing the intercostal spaces. The 
abdomen is flat or deeply sunken below the strikingly prominent 
pelvic bones. The extremities are mere skin and bone and their 



Irregular 
fever. 



Night- 
sweats. 



Pleurisy. 

Dysphagia. 

Hemoptysis 



Character- 
istic facies. 



Contracted 
thorax. 



362 



COMMUNICABLE DISEASES. 



Pulmonary 
consolidation. 



epiphyseal ends seem greatly enlarged as they protrude through 
the wasted, arid integument. 

The physical signs vary with the stage, location and extent 
of the lesions. As already mentioned tuberculosis of the 
bronchial glands may by physical examination entirely escape 
observation. The same holds true of cases where the tubercles 

are scattered throughout 
the lungs and do not 
coalesce. On the other 
hand, where pulmonary 
consolidation (tubercu- 
lous pneumonia) occurs 
early and progresses 
rapidly, the physical signs 
resemble those of ordi- 
nary pneumonia, i.e., dull- 
ness on percussion, pro- 
longed expiration, in- 
creased vocal fremitus ; 
fine, coarse and crepitant 
rales, and bronchial 
breathing. To these may 
be added the physical 
signs of dry or serohemor- 
rhagic pleurisy (see page 
275), which frequently ac- 
companies phthisis pul- 
monalis. Where cavities 
are formed, the physical signs consist of cavernous respiration, 
bronchophony or pectoriloquy. The percussion resonance is 
amphoric, if the walls around the cavity are thin and tense ; 
cracked-pot sound, if the walls are thin and relaxed ; and dull, 
if the walls are thick. If pneumothorax is present, the 
percussion sound is tympanitic, and the respiratory murmur is 
lost ; while hydropneumothorax gives rise to tympanitic resonance 
above water line, dullness below, and metallic tinkling on 
auscultation. 

The poignancy of the clinical picture just depicted notwith- 
standing, errors of diagnosis are quite possible. Pulmonary 
diagnosis, phthisis may readily be confounded with bronchial dilatation, 
localized empyema, fetid bronchitis, pulmonary gangrene and 




Fig. 98. — Phthisis Pulmonum (child 
20 months old). (Sheffield.) 



Cavernous 
breathing. 



Cracked-pot 
sound. 



Differential 



TUBERCULOSIS. 363 

syphilis. In view of the prognostic importance of an early 
diagnosis of tuberculosis, it is imperative to employ every means 
of diagnosis i especially repeated examination of the sputum, 
and the tuberculin reaction i to clear up all doubt. 

The course and duration of phthisis pulmontmi ranges within 
very wide limits. Xot only is it true that ttiberctdosis may pro- 
ceed a latent cotirse for months or years and suddenly break out 
— often after some trivial cause, such as vaccination, measles, 
etc. — and rapidly end fatally under symptoms of lobular or lobar 
pneimionia and the like, but post-mortem examinations have 
repeatedly established the fact that after existing for some time. Exceptionally 
with or without indications of their presence, tubercttlous lesions heaimg. 
may heal spontaneously never to return. As a rule, however. 
pulmonar}- phthisis in yotmg children rims quite an acute course. 
Unless the disease is arrested in its incipiency. infants usually 
succumb to it within from four to eight weeks, either from the 
immediate eftects of the pulmonary lesions or as a result of 
generalized tuberculosis not rarely of the miliary variety. In 
older children the disease pursues a less violent course, and, as in 
adults, shows a tendency to remain localized at its originally in- 
fected focus until a very late stage of the disease. If the tuber- 
culous process is allowed to continue, death invariably occurs in 
from two to three years or earlier — either from asthenia i with 
symptoms of gradual exhaustion, profound anemia, dropsy, etc. ) 
or from apnea i suitocation by sudden hemorrhage, rupture of 
large cavity, pulmonar}- edema, etc.'i. On the other hand, if the 
tubercidous process is detected in its iiicipioicy — which is quite 
possible with the existing modern diagnostic methods — and im- 
mediately and energetically treated, the chances for arrest and 
eventual cure of consumption of the lungs are very good indeed. 

The treatment comprises outdoor life, good food, personal 
hygiene, and symptomatic medication. \Mienever possible, tuber- ouidoc^ 
culous children should be sent to country regions where the ^^^^• 
climate is dry and of equable temperature, so as to allow the 
patients to enjoy outdoor air the greater part of the day. The 
climates of Xew ^vlexico. Arizona, and Eg}-pt are best suited 
for the purpose, although a great many patients will be found to 
do well in Colorado, in the Adirondacks and Sullivan County of 
Xew York, in ^^lontana. Wyoming and X'orth Carolina. Those 
financially incapacitated to take advantage of these climates 
should be removed to climatically less favorable mountain regions 



364 COMMUNICABLE DISEASES. 

or even to ordinary city suburbs, but at all events should not 
be left to perish in overcrowded, unsanitary tenement districts. 
It is often of great advantage to place the child in an up-to-date 
treatment Sanitarium — if possible in a private room — as the principles of 
the treatment are more accurately enforced (and with less resist- 
ance on the part of the patient) under the supervision of a 
reliable physician and nurse of a properly conducted sanitarium, 
than at the patient's residence among his timid and sympathetic 
immediate relatives. 

The diet should vary with the age of the patient, but should be 
nutritious highly nutritious and liberal. Milk, meat, eggs, fresh fish, oat- 
meal, peas, beans and lentils, carrots, spinach, asparagus, potatoes, 
etc., in addition to an ample supply of bread and butter, should 
form the principal components of the regular meals. Between 
meals the child should receive plenty of fresh fruit or fruit 
juices, and, to satisfy its craving for condiments, a small portion 
of milk chocolate or calf's foot jelly. 

The room occupied by the patient should be large and airy. 
Airy room, and its wiudows Open day and night, irrespective of season or 
weather. The child should sleep alone. In addition to a warm 
cleansing soap bath once a week it should receive a cool sponge 
bath twice a day followed by brisk rubbing of the entire body. 
The underwear should be of thin silk or wool, and the outer 
garments should vary with the season of the year — always suffi- 
cient to keep the patient comfortably warm. In the absence of 
fever or circulatory disturbance light exercise that does not 
fatigue acts very beneficially. Horseback riding is highly to be 
recommended. 

The value of drugs as auxiliaries in the successful manage- 
ment of pulmonary tuberculosis should not be underestimated. 
Creosote, j^ {^ j^ot vcry loug ago that creosote was almost universally hailed 
as the specific against consumption. And, while its curative 
claims had been (as is always being done with new methods of 
treatment) grossly exaggerated, its efficiency to relieve distressing 
symptoms (useless cough), and to aid in arresting the further 
spread of the tuberculous lesion cannot wholly be denied. Creo- 
sote should be given in small gradually enlarged doses, well 
diluted in milk, malt extract or red wine. Another drug-mixture 
deserving of trial is the compound syrup of hypophosphites. It is 
Cod-liver ^ uscful touic, and may advantageously be combined with malt 
°^^- and cod-liver oil, as follows : — 



TUBERCULOSIS. 



365 



IJ Olei morrhuse ; . 5iv 

Extracti malti, 

Syrupi hypophosph. comp aa 5j 

Glycerini 3iv 

Pulveris acaciaj 3iv 

Aquae cinnamomi q. s. ad Sviij 

M. Sig. : One teaspoonful three times a day. 



120 

30 

15 

15 

240 



Opiates. 



The bowels should be kept open, and the appetite improved Tonics, 
by means of bitter tonics, especially nux vomica and the 
tincture of cinchona compound. 

In incipient phthisis it is very rarely necessary to resort to 
opiates or its derivatives to check the cough, but when the latter 
is distressing, especially at night, those remedies should be cau- 
tiously administered as often as indicated. 

The management of advanced cases of tuberculosis of the 
lungs is essentially the same as in incipient cases, except that one 
is often called upon to arrest hemoptysis (ice-bag to the chest, 
morphine hypodermatically), to check hyperidrosis (sponging of 
the body with a strong alum solution, atropine by mouth or 
hypodermatically), and to strengthen the heart's action (digitalis 
and strychnine). In the presence of the aforementioned compli- 
cations, however, very few children survive — do what you will. 
Like the flickering flame of the candle end, after many ups and 
downs, slowly but surely, life is extinguished — often at a time 
when the patient seems on the mend. 



Arrest of 
hemorrhage. 



TUBERCULOSIS OF THE BRAIN. 

Brain tuberculosis in children occurs (1) as partial manifes- 
tation of general tuberculosis, (2) as tuberculous meningitis, and 
(3) as brain tumors. The brain lesions are essentially the same 
in the three clinical types of the disease. They consist in the 
deposit of tubercles in the brain substance which vary in size 
from a millet seed to that of a hen's tgg. In tuberculous menin- 
gitis we find in addition inflammation of the pia mater of the 
brain and sometimes also of the cord and transudation into the 
ventricles (chronic hydrocephalus). The tubercles are usually Hyd 
located in the gray matter — in the large ganglia, in the pons and in 
the cerebellum — and occasionally also in the white substance. 
During life, however, it is extremely diflicult to determine the 
seat of the lesion, except when the latter is large enough to exert 
pressure upon vital structures which in their turn give rise to 
focal symptoms — as, for example, paralysis of the cranial nerves 



Variously 

sized 

tubercles. 



ro- 
cephalus. 



166 



COMMUNICABLE DISEASES. 



Headache, 
convulsions 
and paral- 
ysis. 



in disease of the pons. In absence of such symptoms tuber- 
culosis of the brain may exist for months without being detected. 
This is true especially of brain tuberculosis associated with tuber- 
culosis of other organs. As the disease progresses, the symptom- 
atology becomes clearer. The child suffers from intense headache, 
convulsions, paresis or paralysis of some of the cranial nerves or 
extremities, but even then it is often a matter of conjecture 
whether these pressure symptoms are due to tubercle or to other 
tumors (see Tumors of the Brain, page 524). The diagnosis is 
least difficult when tuberculosis of the brain is manifested by 
meningitis (see page 342). Here lumbar puncture often helps 
to clear up the diagnosis. Recourse should be had also to the 




Fig. 99. — Tuberculosis of the Brain (4 years old). Duriiig 
the protracted course of the disease a marked hypertrichosis 
developed over the entire body, especially the legs. (Sheffield.) 



Post-mortem 
findings. 



tuberculin test, examination of the sputum for tubercle bacilli, 
and ophthalmoscopic inspection of the eyes for choroidal 
tubercles. 

TUBERCULOUS PERITONITIS. 

This condition is the result of dissemination of tubercles over 
the peritoneum, omentum, and adjacent structures. The inflam- 
mation excited by their presence gives rise to a serofibrinous or 
hemorrhagic exudation with gradual agglutination of the inflamed 
portions, caseation and ulceration. Post-mortem examination of 
cases of long standing usually reveals involvement of the mesen- 
teric and retroperitoneal glands, fatty degeneration of the liver, 
tuberculosis of the lungs, and parenchymatous nephritis. 

Tuberculous peritonitis is comparatively rare in children 
under three years of age, but quite frequent in those over this 



TUBERCULOSIS. 



061 



age. The classical A^ariety of tuberculous peritonitis is the 
chronic form. Occasionally, however, it may pursue a subacute, 
or even an acute course with chills, nausea, vomiting, acute 
abdominal pain, and high fever. In the majority of instances 
the disease sets in insidiously, with symptoms of dyspepsia, 
anemia, evening rise of temperature, accelerated respiration and 



Chronic 
course. 




Fi^ 



100. — Tuberculous Peritonitis (15 months oldj. Recovered 
after Laparotomy. (Sheffield.) 



pulse, frequent attacks of colic, and more or less pronounced 
diarrhea. A'erv soon the characteristic svmptoms of the disease ^. , , ^ 

^ Distended 

are in full bloom. The abdomen is distended and its wall often abdomen, 
glistening and traversed by blue lines, the epigastric veins. The 
umbilicus is either effaced or protuberant. The extremities are 
emaciated and contrast strongly with the gradually enlarging Emaciation 
abdomen. Palpation of the latter reveals that its consistence is 



368 



COMMUNICABLE DISEASES. 



Fluid in 

abdominal 

cavity. 



Cord-like 
masses. 



Hectic fever, 

sweats and 

diarrhea. 



Latent 
until late. 



Differentia- 
tion from 
hepatic 
cirrhosis. 



Laparotomy. 



not everywhere uniform. Some portions of the abdomen are flat, 
on percussion eHciting the presence of fluid or nodular masses; 
other portions again are tympanitic, denoting that that part of the 
abdominal enlargement is due to intestinal gases. 

Palpation sometimes confirms the findings on percussion. 
Occasionally hard, cord-like, painful masses and thickened 
omentum or adherent intestinal loops are found, and more rarely 
large tumors or encapsulated abscesses are detected. The latter 
if situated near the navel (periumbilical tuberculous abscess) 
may open and discharge through the navel. The abdominal 
enlargement may persist, or after disappearance of the fluid 
content and formation of fibrous adhesions the abdomen may 
retract, become tray-shaped, and remain so until exitus. 

If not arrested by therapeutic measures the disease usually 
runs a very protracted course — months or even years. Remis- 
sions are not rare, but sooner or later the symptoms return, 
sometimes in acute form ; the patient wastes away, is troubled by 
hectic fever, sweats, diarrhea, hiccough, vomiting, dysuria, 
anuria, and edema of the lower extremities or anasarca, until 
death finally relieves him of his agony. Fatal issue may occur 
also from intercurrent diseases, such as intestinal perforation, 
tuberculosis of the meninges or lungs. 

On the other hand, the prognosis is not as grave if treatment 
is instituted early, provided, of course, that the disease is limited 
to the peritoneum. 

Unfortunately in the early stage of the disease the symptoms 
are not infrequently masked, and a positive diagnosis cannot be 
arrived at until the pathognomonic signs of the disease have made 
their appearance, i.e., abdominal distention, circumscribed dul- 
ness, emaciation, diarrhea (diarrhea, emaciation and glandular 
swelHng are often absent), hectic fever and swelHng of the 
inguinal glands. Even then the peritonitis may be confounded 
with ascites accompanying cirrhosis of the liver or valvular heart 
disease. In such cases the diagnosis may sometimes be settled by 
the tuberculin tests, by a bacteriologic examination of aspirated 
adbominal fluid or by inoculation experiment. 

As spontaneous cure is extremely rare and radical cures by 
laparotomy are quite frequent, the latter mode of treatment 
should be resorted to as soon as practicable. Some authors attrib- 
ute the curative effect of laparotomy to the admission of atmos- 
pheric air to the abdominal cavity, others to hyperemia of the 



TUBERCULOSIS. 8G9 

peritoneum produced by the operation in a manner similar to 
that employed by Bier in the cure of tuberculosis of the extremi- 
ties. Except abundance of sunshine, sojourn at the seashore or Tonics, 
mountains and plenty of wholesome food — which measures 
should be employed also in conjunction with an operation — all 
other medical procedures are only of temporary benelit. 

TUBERCULOSIS OF THE ABDOMINAL ORGANS. 

Aside from the intestinal tract and peritoneum, the spleen, 
liver, pancreas, diaphragm, omentum, suprarenals. and the uro- 
genital system may also be the seat of tuberculous disease. 
Except in the rare instances of invasion of the abdominal organs 
by tubercle bacilli through the general circulation, the abdominal 
organs usuallv become involved secondarilv to intestinal or peri- t:suaiiv 

^ - _ - '^ secondary. 

toneal tuberculosis. As a rule, these latter structures become 
infected primarily by swallowing of food, sputum or necrotic 
tissue from the nasopharynx contaminated by tubercle bacilli. 

INTESTINAL TUBERCULOSIS 
(Tabes Mesenterica). 

The tuberculous lesions are usually found in the lowest por- 
tion of the ileum, ileocecal region and colon. It is manifested by 
a tuberculous infiltration of the solitary follicles and mucosa of 
the intestine, which 2:raduallv undergo softening and caseation and Caseation. 

, ' . ulceration 

finallv break down, leaving behind annular ulcers. Tuberculous and intestinal 

_ _ obstruction. 

inflammation of the large intestine may produce so much swelling 
as to occlude the intestinal lumen. Sooner or later the inflamma- 
tion extends to the mesenteric glands and peritoneum. Occasion- 
ally the lungs and other organs also become involved. 

All these manifestations, however, are observed only at the 
autopsy. During life the symptoms are very obscure. Palpation 
mav reveal enlarged mesenteric glands deep down in the abdomen. Enlarged 

=> o -"^ _ mesenteric 

but more frequentlv owing to meteorism they escape observation, glands, 
and even if palpable are not invariably tuberculous in nature. 
If, however, this symptom is associated with enlargement of other s^^-^born 
glands of the body, stubborn diarrhea fgreenish-gray in color, diarrhea. 
mixed with mucus, pus. and often blood), emaciation and 
cachexia. SAveats and hectic fever, the diagnosis of intestinal 
tuberculosis is fairly certain. The diagnosis is rendered positive rp^-[^gj,pig 
bv the demonstration of tubercle bacilli in the stools. The tuber- bacim in 

stools. 

culin test and examination of the sputa often prove decisive in 

24 



370 COMMUNICABLE DISEASES. 

doubtful cases, and complications, such as perforation of the intes- 
tines with consecutive peritonitis, settle the diagnosis beyond 
doubt. Indeed, in the majority of instances the diagnosis cannot 
be made until these complications arise, a period at which thera- 
peutic measures almost invariably fail. At all events the prog- 
nosis is extremely grave. 

Cases of local tuberculosis detected early and treated energet- 
ically (chiefly surgically) may recover. 

TUBERCULOSIS OF THE GENITOURINARY TRACT. 

Urogenital tuberculosis, especially tuberculosis of the kidneys, 
is quite common in children. It occurs either as a manifestation 
of general tuberculosis or as an independent disease. In the 
latter event it almost invariably begins in one kidney, and from 
here it spreads to the bladder and the other kidney. In the 
beginning the affection is very apt to be overlooked, but, as the 
tuberculous process advances, the symptoms (pain in the region 
of the kidney and ureter, thickening of the ureter — as evinced by 
palpation with the finger in the rectum or vagina — irritability of 
the bladder, albuminuria, pyuria, and often hematuria) become 
hematurfa Sufficiently characteristic as to demand careful, repeated, bacteri- 
VacmMn ologic examination of the urine for tubercle bacilli, and cysto- 
urine. scopic inspection of the bladder for tuberculous lesions. Even 
in the early stage systematic cystoscopic examination of the 
bladder will rarely fail to detect tuberculous nodules and ulcera- 
tion about the opening of one ureter (see Fig. 103). In cases 
of long standing the lesions are often found scattered through- 
out the bladder. As in tuberculosis of other organs the tuberculin 
test should always be employed to corroborate the diagnosis. 
Early recognition of the condition and prompt surgical treat- 
ment are not rarely followed by permanent recovery. 

SCROFULOSIS 
(Tuberculosis of the Skin, Mucous Membranes and Glands). 

The tuberculous nature of the symptom-complex embraced 
by the term "scrofula" is no longer a matter of dispute. The 
disease attacks children with undermined constitution who are 
poorly fed and cared for, are forced to live in damp, dark and 
filthy dwellings, and are exposed to tuberculous infection. 
Portals of ^^^I'ious skiu cruptious, or injuries, exanthemata, decayed teeth, 
entry, ^j^j diseased tonsils and adenoids, among others, serve as the 



TUBERCULOSIS. 



1 



portals of entry to the tubercle bacilli. The immediate result of 
the tubercular infection is hyperplasia, and the more remote Hyperplasia 
effect, caseous degeneration of the parts primarily involved, and degeneSkm. 
frequently secondary infection of the neighboring structures. 




Fig. 101. — A characteristic early tu- 
bercular infiltration, as seen through 
the cystoscope. (Leedham-Greeii.) 



Fig. 102. — A large tubercular ulcer 
below the orifice of the right ureter. 
{Leedham-Green.) 




Fig. 103. — Cystoscopic view of the base of the bladder in a 
case of tuberculosis of the left kidney {Wyatt). The opening of 
the right ureter is normal ; the opening of the left ureter is seen 
to be gaping, the lips edematous and thickened, showing the 
presence of small miliary tubercles. 



Clinically scrofulosis is characterized by simultaneous or suc- 
cessive involvement of the skin, mucous membranes and lymphatic 
glands; chronicity of its course, and a tendency toward slow chroni 
spontaneous recovery, or transition into general tuberculosis. 



COMMUNICABLE DISEASES. 



Suppuration. 
Ulceration. 



Naso- 
pharyngitis. 



Otorrhea. 



Chondritis 

and 

periostitis. 



Phlyctenular 
keratitis. 



Fistulse. 



The skin is the seat of a pustular eruption which resists ordi- 
nary local treatment, generally involves the subcutaneous tissue, 
and breaks down, forming slowly discharging abscesses or indo- 
lent ulcers. It is most frequently situated upon the back and 
nates, but is found also upon the scalp and face — probably 
carried from one part to the other by scratching by means of 
infected fingers. 

Scrofulosis of the mucous membranes is manifested chiefly 
by nasopharyngitis. From the nasopharynx the inflammatory 
process may spread to the ears, eyes, larynx and oral cavity. 

The nasal mucous membrane is red and swollen and dis- 
charges a seropurulent secretion which forms yellowish-green 
crusts within and around the nares, producing snuffling respira- 
tion, and excoriation of the upper Hp. A similar acrid discharge 
is usually observed from the ears (bilateral otorrhea). Both the 
nasal and aural discharges may become purulent and fetid, in 
the first instance, by extension of the inflammation from the 
nasal mucous membrane to the cartilage, periosteum and even 
nasal bones (sometimes marked nasal deformity) ; in the second 
instance, by implication of the middle ear and eventually the 
ossicles, or petrous portions of the temporal bones. 

Scrofulosis of the eyes, the so-called strumous ophthalmia, 
usually begins with redness and swelling of the palpebral mucous 
membrane, and in the majority of cases is soon followed by 
involvement of the cornea, in the form of phlyctenular keratitis, 
with strong lacrimation, pain, and photophobia. The phlyc- 
tenulse are very slow in healing, and show a great tendency to 
leave behind corneal opacities. Blepharoadenitis, madarosis and 
permanent thickening of the edges of the lids are quite common 
accompaniments. 

The lymphatic glands are affected early or late — secondarily 
to the inflammation of the skin and mucous membranes. Except 
their wide distribution the glandular swellings present nothing 
characteristic in the beginning, but as the disease progresses they 
show a marked tendency to undergo caseation and suppuration. 
Furthermore, after evacuation of the pus which usually contains 
tubercle bacilli they rarely cicatrize, but, on the contrary, continue 
as pus-discharging fistulse or indolent ulcers. 

The course of the disease depends greatly upon the vitality 
of the patient and the mode of treatment. It is always chronic. 
Children removed from the obnoxious surroundings frequently 



SPONDYLITIS. 



373 



recover completely. In those not properly cared for the tuber- 
culous process is very prone to spread to the osseous system and 
to the internal organs. Spina ventosa, osteomyelitis and spondy- 
litis form frequent sequelae (for details of these affections the 
reader is referred to the chapter on "Tuberculosis of the Bones," 
page 374). The internal organs, especially the liver, spleen and 
lungs, may be implicated singly or collectively, in which event the 
prognosis, of course, is extremely bad. 



Spina 
ventosa. 




Fig. 104. — Tuberculous xA-xillary Lymphadenitis. (Sheffield.) 



Characteristic as the symptom-complex of scrofulosis seems 
to be, errors of diagnosis are nevertheless very apt to be made. 
The perplexity is often great in the differentiation between j^gggj^^^jigg 
scrofula and inherited syphilis, both of which diseases have many syphilis, 
symptoms in common. In all such doubtful cases it is wise, on 
the one hand, to employ the tuberculin reaction, and examine the 
aural and nasal secretions as well as the pus from scrofulous _, , , 

^ Tubercle 

abscesses for tubercle bacilli, and, on the other, to administer baciiii in 

scrofulosis; 

mercury and look for the spirochsete pallida. One should not f^^g^^^^^/ig^ 
be too hasty in pronouncing a case as scrofulosis because of the 
so-called "torpid habitus" of the patient (pale, flabby, puffed f ace ; 
thick nose, swollen and excoriated upper lip, redness and thick- 



374 



COMMUNICABLE DISEASES. 



Prompt and 

energetic 

treatment. 



Tonics. 



Bodily 
cleanliness. 



ening of the lids), or the presence of adenoids or glandular 
swelling. These symptoms can and often do exist independently 
of tuberculosis. 

Scrofula, hke other forms of tuberculosis, demands early and 
energetic treatment. The patient should be removed from the 
obnoxious influences, well nourished and kept outdoors the 
greater part of the day (see page 352). Internally we should 
administer, for several months in succession, moderately large 
doses of the syrup of the iodid of iron and the syrup of hypo- 
phosphites, as well as cod-liver oil or similar alterative tonics. 
The local treatment, which is of very great importance, essentially 
consists of thorough bodily cleanliness (daily bath with sea salt; 
antiseptic dressings to open wounds, etc.) ; removal of diseased 
foci {e.g., tonsils and adenoids, decayed teeth, caseated glands, 
etc.), and evacuation of pus wherever found. Individual com- 
plications should be vigorously combated according to indica- 
tions. (See bone tuberculosis, below; otitis, page 250; eczema, 
page 591, etc.) As the external lesions are probably the result of 
carrying infectious material from place to place by means of the 
fingers, open wounds (vaccination wounds!) should be thor- 
of open oughly protected and the patient's finger-nails clipped and kept 
scrupulously clean to prevent scratching the diseased parts of 
the body and direct infection of its healthy portions. 

R Syr. f erri iodidi 3iij I 12 

Syr. hypophosph. co q. s. ad Sij | 60 

M. Sig. : 3j three times a day for a child 3 years old. 



Protection 



TUBERCULOSIS OF BONES AND JOINTS 
(Tubercular Osteomyelitis and Arthritis). 

The grouping together of tuberculous bone and joint diseases 
is intended to emphasize their correlation. The favorite seat of 
bone tuberculosis is usually in the epiphyses, the joint becoming 
involved secondarily by extension of the inflammatory process to 
the synovial structures. Occasionally the joint is affected 
primarily. 

The immediate cause of the disease is the tubercle bacillus 

which invades the medullary tissue, the bone proper, or the 

^Il'^^JL^J articular structures, either from within — from a florid or latent 

secondary. ' 

tuberculous focus elsewhere — or from without — as a result of 
traumatism. An inherited predisposition and impaired nutrition 
from various causes favor the development of tuberculous disease. 



TUBERCULOSIS. 



375 



Osseous as well as articular tuberculosis is essentially a 
chronic inflammatory process, free from the violent symptoms chronic 
which are characteristic of acute, non-tuberculous osteomyelitis. p^°^^^^- 
Extensive lesions may exist for weeks and months with appar- 




Fig. 105. — Tuberculous Disease of the Elbow-joint in Boy 18 
Months Old. (Sheffield.) 



ent perfect health. Fever is usually absent in the beginning and 
only slight — in the evening — at a later stage of the disease. As 
the tuberculous process advances progressive anemia and emacia- 
tion make their appearance but are not pathognomonic of the 
affection. The local symptoms also are very vague at first. 
Hence the reason whv local tuberculous disease is frequently 



Emaciation. 



376 . COMMUNICABLE DISEASES. 

Frequently Overlooked until, as will presently be shown, deformity and loss 
overlooked. ^£ function liave occurred, which vary greatly in extent and 
severity with the seat of the lesions and the mode of treatment. 

1. TUBERCULOSIS OF THE VERTEBRAL COLUMN 
(Spondylitis; Pott's Disease). 

The tuberculous process usually begins in or near the verte- 
bral body, and if not arrested, gradually extends to the contiguous 
structures, including the spinal cord. 




Fig. 106. — Pott's Disease (Langerhans) . Kyphosis of dorsal 
vertebrai, the result of caseous tuberculous periostitis and osteo- 
myelitis. Destruction of three thoracic vertebrae. Two-thirds 
natural size. 

It is manifested by an ulcerative and often suppurative 

destruction of the bone, with metastatic — gravitation — abscesses 

in distant locations, e.g., retropharyngeal abscess, in cervical 

and^cnam^ Spondylitis ; psoas abscess, in lower dorsal and lumbar disease. 

ertebrai Furthermore, with softening and crumbling of the vertebral 

bodies, bodics, the spinal column, as it were, topples over, usually back- 

K hosis ^^^d' producing a deformity known as kyphosis, gibbus or Pott's 

hump. The condition is gradually further aggravated by com- 

Lordosis. pensatory spinal deformities (especially lordosis) and a group 



SPONDYLITIS. 



of other distressing pressure symptoms soon to be related which 
if not arrested throw the unfortunate creature in an abyss of 
everlasting misery. 

This process, fortunately, is very slow in development, afford- 
ing ample time — from three to ten years — to arrest and mend its 



Slow onset 
and course. 




Fig. 107. — Cervical Spondylitis. Note broadness and tilting of 
neck. (Sheffield.) 



Four 



ravages and ample warnings to the patient to seek relief. We 
may frequently differentiate four stages in the progress of the ^t^^es. 
affection: 1. The stage of onset, where the symptoms are very 
vague and inconstant. The child shows a disinclination to play, 
refuses to walk or tires easily when it does walk. It complains 
of pain in different parts of the body, following the distribution 
of the spinal nerves, the pain being often so severe, especially 
at night, that it wakes the child from its sleep with a sudden 



Pain, 

especially at 
night. 



378 COMMUNICABLE DISEASES. 

start — "starting pain." 2. The stage of fixation of the spinal 

starting column ; 3, the stage of characteristic deformity; and 4, the stage 

^^^^' of suppuration and pressure paralysis. The disease does not 

always progress to the last stages. In some instances, after two 

or three years' course, either through treatment or spontaneously, 




Fig. 108. — Cervical Spondylitis. Same case as Fig. 107, in brace. 
(Sheffield.) 

solidification of the diseased vertebrae and relative cure occur, 
parafysi^ Rclapscs, howcvcr, are not infrequent. Pressure paralysis (see 
Myelitis) is especially common in disease of the lower cervical 
and upper dorsal, and rare in that below this region. 

The focal symptoms vary with the seat and extent of the 

lesion. In cervical spondylitis the patient, if old enough, com- 

spondymit^ plains of neuralgic pain in the head and upper portion of the neck. 

Very young children indicate the presence of pain by suffering 



SPOXDYLITIS. 379 

and anxious expression of the face, by refusal of food and crying 

on handling. The head is stiff, tipped backward, or laterally Torticollis. 

(torticollis-like), and when the child moves it is often seen to 

support its head with the hands. At a later stage of the disease, 

there are often disturbances of deglutition and voice — not rarely 

due to retropharyngeal abscess. If the uppermost cervical verte- 




Fig. 109. — Dorsal Spondvlitis, Gibbus (12 years old). 

(Sheffield.) 

brae are diseased, there is danger of anterior displacement of the 
head between the atlas and axis, more rarely between the 
occiput and atlas, and death from pressure upon the cord. The 
permanent deformity in cervical spondylitis usually consists of 
thickening and broadening of the neck, and sinking of the head 
upon the shoulders. 

In dorsal spondylitis the distribution of the pain differs some- 
what with the particular part of the spine involved. If the spondylitis. 
upper dorsal vertebra are aft'ected, the pain resembles that of 



Dorsal 



380 COMMUNICABLE DISEASES. 

intercostal neuralgia, and increases on coughing, sneezing, laugh- 
ing, etc., while in spondylitis of the lozver dorsal vertebrae, the 
most frequent seat of the disease, the pain radiates to the lower 
extremities. In disease of this region, furthermore, the upper 
part of the body deviates to the side, one shoulder is elevated 
Scoliosis, ^j^^ ^j^g trunk bent to the opposite side — a state of scoliosis ; at 




Fig. 110. — Dorsal Spondylitis. Same case as Fig. 109, front view. 
{Sheffield.) 

the same time the vertebral column is kept rigid, every move- 
ment carefully avoided, and in walking short rigid steps are 
istk?Stitu^de ^^^^"' ^^^ patient timidly balancing the superincumbent weight 
^^^n walking of the body by firmly supporting the spine with the hands. If 
urged to pick up something from the floor, the child stoops by 
strongly flexing the knee- and hip- joints, while holding the verte- 
bral column perfectly rigid, and raises himself by resting the 
hands upon the thighs, and then, with alternating supporting 



SPONDYLITIS. 



381 



movements along the thighs and trunk, elevates the body and 
lastly extends the legs. If bending of the spinal column is 
attempted, motion occurs only in the healthy sections, the diseased 
portions remaining tirmly fixed. The ultimate spinal deformity 
consists of kyphosis, kyphoscoliosis and lordosis. 

In lumbar disease the patient complains of pain in sitting, 
and refers it also to the lowest portion of the abdomen and the 
legs. The physical signs are essentially the same as in spondylitis 
of the lower dorsals, except that the deformity occurs at a later 
period and is not as pronounced. On the other hand, there is a 
greater tendency toward the formation of psoas abscess — a 
tumor deep in the iliac fossa or at the anterior surface of the 
thigh, lameness and flexion of one thigh. 

Careful attention to the aforementioned physical signs rarely 
fails to disclose the presence of vertebral caries, even at an early 
stage of the disease. Cervical spondylitis may be mistaken for 
torticollis (sudden onset, pain and unilateral contracture more 
pronounced; early response to anodynes and antirheumatics, 
etc.) ; for cervical rib (revealed by X-rays) ; non-tuberculous 
retropharyngeal abscess (immediate relief on puncture). Dorsal 
and lumbar spondylitis may be confounded with rachitic curva- 
ture (rounded in rickets; angular in spondylitis; rachitic kyphosis 
is reducible by placing the child upon the abdomen and over- 
extending the thighs ; absence of characteristic gait and mode of 
stooping). Right iliac psoas abscess often resembles appendicitis 
(onset sudden or recurrent, rigidity of the abdominal muscles, 
absence of spinal disease). Psoas abscess differs from hip-joint 
disease by the hip-joint being fixed in the latter affection; and 
from hernia by being reducible in recumbent posture. 

In view of the comparatively slow course of the disease in 
the majority of cases, the prognosis as to life is good, and as to 
permanent deformity fair, provided the treatment is begun early 
and persisted in. The prognosis is bad in cases presenting 
abscesses, fistulae, and pressure paralysis. Even here surprisingly 
good results are often obtained under suitable treatment. 

The treatment is principally orthopedic and surgical — fixation 
of the spine by a plaster of Paris or (in milder cases) celluloid 
jacket, rest in bed to unburden the spinal column, and evacuation 
of large collections of pus (e.g., retropharyngeal or psoas 
abscesses). Good hyeiene, outdoor air, plenty of nutritious food, 
and iron, hypophosphites, and cod-liver oil will facilitate a cure. 



Attitude in 
bending. 



Kypho- 
scoliosi 



Psoas 
abscess. 



Differentia- 
tion from 
torticollis, 
cervical rib, 
retropharyn- 
geal abscess 
and rachitic 
kyphosis. 



Differentia- 
tion of right 
psoas abscess 
from appen- 
dicitis, 
coxitis and 
inguinal 
hernia. 



Fixation. 



Evacuation 
of pus. 



382 



COMMUNICABLE DISEASES. 



SCOLIOSISi 
(Lateral Curvature of the Spine). 

In contrast to the aforementioned spinal deformities. 

Habitual. |-]^is form of scoHosis is not tuberculous. As a rule, it is habitual 

in nature, the result of unequal (one-side) compression of the 




Fig. 111. — Lateral Spinal Curvature. Second degree. (Sheffield.) 



intervertebral cartilages, favored by atony of the muscles and 

compressicfn ligaments and weakness of the bones. It is most frequently 

vertebral obscrvcd in school children, especially girls, and is generally 

ages. ^g(.j.j|3g(j ^Q faulty posture while sitting at the school desk, etc., 

and to the habitual carrying of heavy books with one arm. I 

firmly believe that a great many cases of the so-called habitual 



1 This spinal, non-tuberculous deformity is discussed here in order 
to emphasize its differences from spondylitis. 



SCOLIOSIS. 



183 



lateral spinal curvatures originate during early infancy in con- 
nection with rachitis (q. v.), are generally overlooked while Rachitic, 
the deformity is slight and are detected later, at a time when 
the deformity does and would gradually get worse, whether 
or not the child goes to school. Of course, this view does not 




Fig. 112. — Lateral Spinal Curvature. Same case as Fig. 111. Side 
view. (Sheffield.) 



preclude the fact that faulty posture and encumbrance of one- 
half of the body hasten to aggravate the curvature. Less fre- 
quent causes are obliquity of the pelvis (e.g., shortening of 
one lower extremity from birth or postnatal disease) ; uni- 
lateral paralysis (e.g., poliomyelitis, progressive muscular 
atrophy) ; unilateral immobility of the thorax (e.g., protracted 
extensive pleuritic exudation or adhesions) ; and unilateral 
sinking of the thorax from traumatism or operations (e.g., 



static. 



Paralytic. 



Cicatricial. 



384 



COMMUNICABLE DISEASES. 



multiple fractures of ribs, resection of ribs in pyothorax). Very 
Congenital, rarely scoliosis is congenital in nature, when, as a rule, it is 
associated with other congenital malformations. 

Scoliosis is manifested first by elevation of one shoulder. 

High and later by prominence of one hip and scapula on the same 

side and gradually increasing convexity of the spinal column 




Fig. 113. — Rachitic scoliotic skeleton. (Grandin, Janiimi and Marx.) 

and side. With further progress of the deformity, the spinal 
curvafif/e. column presents two curves, in the shape of the letter S (see Figs. 
115 and 116) — the primary curve, which is usually in the dorsal 
region, and the secondary or compensatory curve, usually in the 
lumbar region. Bad cases are occasionally complicated also by 
Lordosis, lordosis, deformity of the thorax and displacement of the heart 
and lungs, but are otherwise free from constitutional 
symptoms. 

Fortunately, nowadays, with the greater attention being 
paid to the general health of children, these dreadful deformi- 



SCOLIOSIS. 



385 



ties are very rarely encountered. Many cases come under 
the care of the physician in the first stage of the disease which 
ordinarily yields to massage, calisthenics, fresh air, ample calisthenics. 
nutrition, general medicinal tonics, and, above all, removal of 
etiologic factors. Severer forms of scoliosis are often cor- 

"PI Q ct PT*- 

rected by a plaster-of-Paris or celluloid corset — worn con- jacket. 




Fig. 114. — Paralytic Scoliosis. Same case as Fig. 173, 
posterior view. (Sheffield.) 

tinuously for several months, and followed by massage and 

exercise to strengthen the weak muscles. Fixed scoliosis can 

at best only be impeded in its further progress, but the damage 

done is frequently irreparable. Hence, the importance of 

early and energetic treatment, and particularly of prophylactic Prophylaxis. 

measures, which are especially effective in habitual scoliosis. 

Here the school physician is offered many opportunities to 

merit the gratitude of the community. 



386 COMMUNICABLE DISEASES. 

2. MORBUS COXARIUS 

(Hip-joint Disease, Coxitis Tuberculosa, Articular Osteitis 

of the Hip). 

The pathologic process of this tuberculous affection is usually 
Osteitis, described as consisting of three stages : 1, the stage of osteitis^ 




Fig. 115. — Lateral Spinal Curvature (S-shaped scoliosis; see 
page 384). (Sheffield.) 

as a rule, involving the femoral head, less frequently the acetab- 
suppuration. ulum ; 2, the stage of arthritis or suppuration, in which all the 
joint structures are implicated; and 3, the stage of disintegra- 
tion and absorption of the head and sometimes the neck of the 
femur and the upper and back part of the acetabulum, with 
Displace- "wandering" of the head of the femur upward and backward 

ment. <=" 

Upon the dorsum ilii. 

Simultaneously with the onset of the first stage of the patho- 



COXITIS TUBERCULOSA. 387 

logic process, or sometimes at a later period, the child begins to 
limp and to complain of pain in the knee- or hip- joint or both. Limp. 
As a rule, 'the limp at first is intermittent in character, more pain in 
marked either in the morning or in the evening, but as the inflam- 
mation progresses it becomes constant and quite pronounced, the 




Rigidity. 
False posi- 



Fig. 116.— 'Lateral Spinal Curvature (S-shaped scoliosis). Same as 
case Fig. 115. Side view. {Sheffield.) 

leg at the same time being held very rigid. With the occurrence 
of articular exudation, the leg assumes a pathognomonic position 
of flexion, abduction and eversion, and the patient in order to ^^^^ °^ ^^^ 
bring the foot to the ground depresses the pelvis on the affected 
side, thus giving rise to slight — apparent — lengthening of the ^^gtJIn^n 
limb. With destruction of the joint and the articular bony struc- 
tures, the hip- joint becomes further flexed, inverted and adducted. 
To overcome the uselessness of the limb in this position the 



388 



COMMUNICABLE DISEASES. 



Apparent 
shortening. 



Compen- 
satory 
scoliosis 
and 
lordosis. 



Starting 
pain. 



Tumefaction. 



patient elevates the pelvis on the affected side, and to counteract 
the — apparent — shortening he steps on the ball of the foot. 
Later real shortening ensues, owing to the wandering of the 

femoral head upward and 
backward, and firm contrac- 
tion and atrophy of the 
muscles. 

In upright posture, in con- 
sequence of the pelvic obli- 
quity, the patient assumes a 
position of compensatory sco- 
liosis and lordosis. In re- 
cumbent posture, with the 
limbs brought down parallel 
to each other, there is always 
compensatory lordosis of the 
lumbar region. This lordosis 
disappears on flexing the af- 
fected limb at the hip to an 
angle at which it is held 
flexed by the contracted 
muscles. 

The intensity of the pain 
varies. It is usually worse 
after manipulation and 
fatigue, and at night. It may 
awaken the child from its 
sound sleep with a cry (''start- 
ing pain''). The pain not 
rarely is referred to the knee, 
or to other parts supplied by 
the obturator nerve, e.g., the 
inner side of the thigh. Hence 
the importance of always 
examining the hip-joint in such cases. 

In addition to the pain, the limp and false position, we may 
find at a late stage of the disease involvement of the inguinal 
glands, with or without suppuration and perforation; enlarge- 
ment — "white swelling" — of the hip; flattening of the gluteal 
region and effacement of one gluteal fold; multiple abscesses 
and fistulas at various points of the hip or thigh, especially at the 




Fig. 117. — Hip-joint Disease. 
(Sheffield.) 



COXITIS TUBERCULOSA. 



;58i) 



tensor fasciae latae; irregular temperature, especially during the 
stage of suppuration. 

Cases presenting the aforementioned typical symptoms are 
recognizable at a glance. Indeed, at this late stage of the cHsease, 
it is almost immaterial whether a correct diagnosis is made or not, 
since a fatal issue from exhaustion, amyloid degeneration and 
general tuberculosis is all that can be expected, particularly in 
children with a tuberculous diathesis. The center of the physi- 
cian's interest therefore should rest upon the diagnosis of incip- 
ient coxitis which, if properly treated, offers good prospect of 
recovery. A history of slight trauma ; occasional dragging of the 



Irregular 
temperature. 



Exhaustion. 




Fig. 118. — Hip-joint Disease. Note compensatory lordosis on full 
extension of affected limb. (Sheffield.) 



leg or Hmping; pain in the hip- or knee-joint; disinclination to 
play and undue fatigue after slight exertion ; restless sleep and 
''starting pain," all point to coxitis and demand very careful 
and repeated examinations of the hip-joint. The diagnosis is 
greatly facilitated and in the majority of instances rendered 
positive by the presence of pain on pressure against the tro- 
chanter, or against the acetabulum (by digital rectal examination), 
and von Pirquet's tuberculin test. Advanced coxitis can readily 
be diagnosed by the aforementioned faulty attitude of the 
patient, in recumbency, standing, or walking. In doubtful cases, 
an X-ray examination (by an experienced radiographer) is 
decisive. The latter procedure is especially useful in differenti- 
ating coxitis from: Injury to the hip (disabihty follows imme- 
diately after the accident; local signs of injury, e.g., ecchymosis, 
etc.) ; coxa vara (X-ray shows downward inflexion of the neck 
of the femur; adduction and extension of the limb are usually 



X-ray in 
differentia- 
tion from 
trauma of hip 
and coxa 
vara. 



390 



COMMUNICABLE DISEASES. 



Differentiation 
from 
Congenital 
dislocation 
of hip; 
osteo- 
myelitis; 
rheumatism; 
lumbar 
spondylitis; 
hysteria, 



possible) ; congenital dislocation of the hip (history of lameness 
from birth ; absence of inflammatory signs or limitation of 
motion) ; osteomyelitis with separation of the epiphyses (very 
violent course); rheumatism (yields to the salicylates; no bone 
lesion) ; spondylitis of the lumbar region (distinct symptoms of 
spondylitis; hip-joint free); hysteria (absence of joint trouble, 
best proven under anesthesia, and by means of X-rays) ; perios- 




119. — Sarcoma of the Femur in a Girl 8 Years Old. 
(Sheffield.) 



and sarcoma teal sarcoma of the trochanter (see Fig. 119) (swelling rapidly 
part of increases in size; marked dilatation of the superficial veins). 

femur. _ ... . 

The treatment consists of : reduction of existing deformity, 

either gradually (by weight and pulley, while the patient is in 

„ ^ ,. bed) or forcibly (under anesthesia) ; disencumbrance of the 

Reduction ■ -' • ^ ' 

of deformity, hip- joint of the body weight, at first by rest in bed (bed extension 
and rest, apparatus, so as to enable the patient to enjoy fresh air) and 
later by means of an extension-walking apparatus ; and, finally, 
fixation of the hip- joint by a plaster-of -Paris spica or a fixation 
apparatus. Fixation of the joint as well as extension should be 
continued for some time after apparent recovery. Constitutional 



KNEE-JOIXT DISEASE. 



391 



treatment. Massage to prevent atrophy of the muscles and Massage, 
stiffness of the healthy joints. 

3. KNEE-JOINT DISEASE 
(Tuberculosis o£ the Knee-joint. White Swelling). 

The pathologic process of tuberculosis of the knee-joint 
resembles that of the hip. It may begin in the synovial mem- 




Fig. 120. — Tuberculous Disease of the Knee-joint in a Child 
13 Months Old. Patient succumbed to tuberculous pyothorax. 
(Sheffield.) 

brane or in the articular ends of the osseous structures. The 
clinical symptoms are practically the same, whether the synovialis pugiform 
has been affected primarily or secondarily. They consist of fusi- spelling, 
form swelling, local tenderness, atrophy of the thigh and calf 



392 COMMUNICABLE DISEASES. 

muscles, flexion and slight outward rotation of the knee, and later 
abscess formation (extra- or intra-articular). During the sup- 
purative stage, less frequently in the absence of suppuration, 
there are more or less constitutional symptoms, such as anorexia, 
anemia, emaciation and irregular fever. The latter is quite high 
in the presence of secondary infection. 

The tuberculous process pursues a rather slow course. Not 
rarely it is interrupted by prolonged remissions. Exacerbations 
are often induced by local trauma or intercurrent acute diseases, 
sometimes after an "apparent" cure had been established. The 
prognosis as a whole, however, is favorable, if treatment is begun 
early and properly. The very rarely occurring spontaneous 
recovery should not be depended upon. 

Within recent years the treatment of tuberculosis of the knee- 
joint, as well as that of the other smaller joints, has been entirely 
revolutionized. Instead of resorting to immobilization, resection 
and permanent fixation, Bier's method of passive hyperemia has 
become the treatment of choice, since it not only aids nature in 
the healing of the tuberculous process, but tends also to restore the 
normal functions of the afifected joint. The mode of procedure 
is very simple. A soft-rubber bandage about 2 inches in width is 
applied gently and evenly around the extremity, at some distance 
above the lesion, e.g., at the middle or upper third of the femur 
in tuberculosis of the knee-joint, and left in place for an hour 
or two, once or twice a day. If the bandage is properly applied it 
gives rise to no pain, nor interruption of the pulse. The ex- 
tremity below the bandage soon swells slightly, and assumes a 
bluish-red color, but remains warm. The favorable results 
obtained from this mode of treatment of tuberculous joints are 
rather slow in coming (from three to nine months), but in uncom- 
plicated cases well worth waiting for. Complications arising 
should be treated symptomatically. Thus cold abscesses call for 
trea^Sent. free incisions and evacuation (may be enhanced by cupping- 
glass) of the necrosed tissue ; large exudations should be treated 
by aspiration and injection of iodoform emulsion, and the general 
health should be improved by outdoor fresh air, nutritious food, 
tonics (iron and cod-liver oil), massage and hydrotherapy. For 
differential diagnosis, see "Arthritis," page 419. 



SPINA VENTOSA. 



393 



4. SPINA VENTOSA 

(Tuberculosis of the Metacarpals and Phalanges. 

Tuberculous Dactylitis). 

This disease most frequently affects the first phalanx of the 
index finger, but may occasionally be found simultaneously in 
several phalanges or metacarpals of the same hand. The osseous 
tissue is gradually destroyed, and, while this is going on, here and 
there new bone tissue is gradually formed under the periosteum. 



Usually- 
first phalanx. 



W 





Fig. 121. — Spina Ventosa. {Sheffield.) 



In consequence of the latter process, the finger becomes fusiform, 
as if the bone had been "blown up" (see Fig. 121). As the inflam- 
matory process is very slow and painless, it, as a rule, takes sev- 
eral months before the characteristic appearance is developed. 
At a later stage of the disease, there is circumscribed redness, fluc- 
tuation, impairment of function of the tendons and spontaneous 
rupture of the suppurating focus with very tedious discharge of 
the contents. 

Tuberculous dactylitis may be mistaken for a congenital or 
acquired syphilitic lesion. The history of syphilis, the presence 
of other syphilitic symptoms, the greater tendency of syphilitic 
dactylitis to be multiple and symmetrical, and the ready response 



Fusiform 
swelling. 



Differentia- 
tion from 
syphilis. 



394 COMMUNICABLE DISEASES. 

to antisyphilitic treatment usually suffice to clear up the diag- 
nosis. A positive von Pirquet tuberculin test and the coincidence 
of tuberculous lesions elsewhere point strongly to tuberculosis. 
Early constitutional treatment and passive hyperemia (see 
ConservativQ page 392) are very efficient curative measures. Conservative 
surgery (evacuation of pus and sequestra) is indicated in neg- 
lected cases. In these recovery is slow, usually with permanent 
deformity. 

NON-TUBERCULOUS OSTEOMYELITIS 

(Osteitis; Periostitis). 

The term osteomyelitis refers chiefly to inflammation of the 
marrow of the bone, but includes also the morbidity of the bony 
matrix and periosteum, which at one period or another partici- 
pate in the destructive processes. 

Osteomyelitis is exceedingly common in children below the 
age of puberty — before completion of ossification of the epiphyses 
and diaphyses — since the anatomic peculiarities of the circulation 
in growing bones particularly favor its development on slight 
provocation. The affection is observed in two forms : Non- 
tuberculous and tuberculous (see page 374). Non-tuberculous 
osteomyelitis most frequently affects the long bones of the lower 
Affects extremity (femur and tibia), less often the other long bones, and 
exceptionally the short bones of the body. In most instances it 
Microbic is the rcsult of infection of the medullary tissue by pus microbes, 
especially the staphylococcus and streptococcus, which enter the 
blood from suppurating wounds of the skin (pustular eruption!) 
or pathologic foci in the respiratory or alimentary tract. As 
predisposing and contributory causes we may mention the various 
contagious and infectious diseases, such as typhoid, scarlatina, 
measles, pneumonia, sepsis neonatorum, etc., all of which being 
instrumental in lowering the vitality and resistance of the patient. 

Infection of the medullary tissue once established, the patho- 
vioient log-ic proccss is very acute and violent. If left alone the inflam- 

course. ox- j 

matory process rapidly goes on to suppuration, leading to loosen- 
ing of the periosteum and bone necrosis and separation of the 
Diaphyso- diaphysis from its epiphysis. If the patient survives and the 

epiphyseal _ ^ -^ . . 

separation, inflammatory process subsides, there is a separation of the dead 
bone (sequestrum) from the living. Unless removed the seques- 
trum may remain an everlasting source of irritation and sup- 
puration. 



NON-TUBERCULOUS OSTEOMYELITIS. 



395 



The osteomyelitic process is ushered in by a chill, rapid rise 
of temperature and pulse and other symptoms which usually symptoms 
accompany acute suppurative affections. Before the appearance tion."^^^^^' 
of the local symptoms the disease is very apt to be mistaken for a 
pyemic or typhoidal condition, and in infants unable to indicate 
the presence of local pain osteomyelitis may end fatally before 
a correct diagnosis has been arrived at. Hence the importance 
of a careful examination of the bony system in all febrile affec- 
tions with indefinite source. 




Fig. 122. — Osteomyelitis of Tibia (2 weeks old). Compli- 
cated by Extension of Phlegmonous Inflammation to the Prepa- 
tellar Bursa. (Seiui.) 



The local symptoms of osteomyelitis are : Pain, tenderness, 
swelling, redness, synovitis, epiphyseolysis, and loss of function. 

The pain is excruciating, boring or throbbing, worse at night, 
and increases in intensity as the exudation becomes more abun- 
dant. Young children are rarely capable of locating the exact seat 
of the pain, but usually refer to the entire affected limb. As a 
rule, the pain disappears suddenly with the escape of the inflam- 
matory products from the interior to the exterior of the bone. 

Tenderness on pressure can be detected early, and is most 
severe where the inflammation has approached nearest the surface 
of the bone. Where the disease is located deeply in the medulla, 
tenderness can readily be elicited by percussion. 



Excruciat- 
ing pain. 



Tenderness 
on pressure. 



396 



COMMUNICABLE DISEASES. 



Edema. 



Pus. 



Epiphyse- 
olysis. 



Embolism. 



Swelling and redness are not discernible until the inflamma- 
tion has reached the periosteum. Thrombophlebitis and edema, 
however, are often early symptoms. 

Synovitis is the rule where the disease affects the epiphysis 
as well as the end of the diaphysis. The intraarticular effusion 
is at first serous, the result of vascular disturbance, but as the 
suppurative process in the bone advances, the effusion becomes 
purulent by direct extension of the infection. The character of 
the effusion can readily be determined by exploratory puncture. 

Epiphyseolysis, or separation of an epiphysis from the diaphy- 
sis, is a late symptom, or rather a complication. It may be recog- 
nized by soft crepitation between the separated parts, false point 
of mobility and displacement — signs of fracture. 

Loss of function of the limb is invariably present, and as the 
disease advances there are marked contractures. The patient 
instinctively assumes such postures as will best relax the muscles 
and ligaments connected with the affected area, and thus prevent 
painful tension. 

These symptoms if closely kept in view will generally avoid 
errors in the diagnosis. Typhoid fever can readily be excluded 
even before the development of local symptoms by the presence 
of marked leucocytosis in osteomyelitis. For differential points 
between osteomyelitis and arthritides, see page 420. 

As previously indicated the course of the disease varies with 
the degree of infection and the aggressiveness of the treatment. 
Early operative interference is usually followed by recovery in 
the great majority of cases. In some cases the infection is 
extremely violent and death occurs within the first thirty-six 
hours, before (or in spite of that) a diagnosis had been made and 
the appropriate therapeutic measures employed. The great dan- 
ger in osteomyelitis is the tendency to venous and arterial throm- 
bosis with secondary embolism and abscesses in different parts of 
the body, especially the lungs, heart and kidneys. 

With subsidence of the acute symptoms, the osteomyelitic 
process is not always at an end. Transition into chronic osteo- 
myelitis is not uncommon (for details see treatise on surgery). 
Suppurating sinuses leading down to the infected sequestra may 
indefinitely persist, and, with occasional improvement, continue 
to undermine the vitality of the patient. Amyloid disease of 
various viscera (liver, q. v.) may form a sequel of prolonged sup- 
puration. 



XOX-TUBERCULOUS OSTEOMYELITIS. 



397 




Fig. 123. — Osteomyelitis of the Radius. Enlargement of the entire 
bone and three well-defined abscess-cavities. {Scnn.) 



398 



COMMUNICABLE DISEASES. 



SYPHILIS HEREDITARIA S. CONGENITA 

(Syphilis Embryonalis or Foetalis, Syphilis Neonatorum, Syphilis 
Hereditaria Tarda). 

Congenital syphilis is due to a specific micro-organism, the 
^^^paHida! spirochsetc pallida, which is transmitted to the embryo or fetus 




Fig. 124. — Congenital Syphilis (3 weeks old). Note peculiar 
deformity of feet, excoriation of upper lip, tumefaction on fore- 
head. (Sheffield.) 



either through the syphilitic semen (ex patre), ovule (ex matre), 
or maternal blood (at any time during pregnancy). 

The great majority of syphilitic embryos or fetuses are 
Few aborted. The few that survive may pass through the syphilitic 

survive. , ; ^ . ° . 

process in utero (syphilis embryonalis or foetalis) and emerge mto 
the world either dead or in a shriveled, shrunken, emaciated or 
disfigured (hydrocephalus, spina bifida, etc.) condition, and, as a 
rule, succumb soon after birth; or the fetus may maintain a 



SYPHILIS. 399 

good state of health during intra-uterine Hfe, be born in appar- 
ently perfect health, and develop the syphilitic manifestations 
soon after birth {syphilis neonatorum), or not until several years 
after (syphilis hereditaria tarda.) 

Having fully discussed "syphilis embryonalis" in connection 
with "feeble vitality of the newly born" (q.-v.), we will limit our 
present remarks to syphilis of the newly born and to late syphilis. 

SYPHILIS NEONATORUM. 

As previously alluded to, the infant may at birth appear per- 
fectly healthy. It may continue to thrive, especially if fed on 




tig. 125. — Congenital Syphilis (0 weeks old). Note maculo- 
papular eruption. (SJieffield.) 

breast milk. Before long, however, — usually after from about 
one week to three months — the clinical aspect changes materially. 
The baby begins to breathe noisily, especially while it nurses, ^^^Yhin 
"sniffles," becomes hoarse, or loses its voice entirely. The nurse ozena. 
or the weather is blamed for the baby's "cold in the head," until 
examination reveals that the syphilitic coryza is associated with 
swelling of the nasal mucous membrane and occlusion of the 
anterior nares by a seromucous or serosanguinolent discharge 
and incrustation. Inspection of the mouth and throat often dis- 
closes grayish-white patches (plaques muqueuses) upon the Mucous 
mucous membrane of the mouth and pharynx, more rarely papil- 
lomatous vegetations, and occasionally edema glottidis, which 
latter may lead to fatal termination. Not rarely the inflamma- 
tion of the nasal mucous membrane extends to the nasal 



400 



COMMUNICABLE DISEASES. 



Saddle- 
shaped 
nose. 



Skin 
lesions. 



periosteum and perichondrium, arresting the development of the 
nasal bones, and giving rise to the peculiar sinking of the bridge 
of the nose which is generally designated "saddle nose." 

The syphilitic manifestations augment from day to day. The 
skin assumes a peculiar light- or dark-yellow (copper) color, is 
dry and hard to the touch, and soon becomes covered by an 
eruption which is typical for its multiplicity and variability. 
Almost every kind of skin disease is represented. Papules, 
vesicles, pustules, smooth and scaly patches, tubercles, wheals, 
macules, hemorrhagic spots, simple redness, scabs, ulcers, etc., 




Fig. 126. — Congenital Syphilis. Same case as Fig. 125. Note pro- 
truding condylomata at anus. {Sheffield.) 

Rhagades. ^^^ with oue another in their supremacy, and rhagades surround 
the different external orifices of the body (angles of the eyelids 
and lips, at the alse nasi, anus, labise vaginae, etc.). The hairy 
portions of the body also participate in the syphilitic process. 
^°hair! The hair of the scalp, eyebrows and eyelashes rapidly fall out 
and are very slow in returning. The nails undergo certain 
alterations, such as thickening, claw-like deformities, suppura- 
tive inflammation (onychitis) and exfoliation (paronychia), the 
process not rarely extending also to the phalanges (syphilitic 
phalangitis, q.v.). In the majority of cases we find a bullous 
eruption which is pathognomonic of grave syphilitic infection, 
Pemphigus, i-^; pcmphigus Syphiliticus. It usually sets in within the 
first week after birth as flaccid, yellow or brownish vesicles, 
surrounded by an areola of dry epidermis or excoriation. The 
bullae vary in size from a pinhead to a cherry, burst readily and 



Onychitis. 



SYPHILIS. 401 

discharge a seropurulent or serosanguinolent content. They are 
distributed all over the body, but particularly over the palms of Differentia 
the hands and soles of the feet — herein differing from non-syphi- 
litic pemphigus which but rarely aff'ects these parts. In conse- 
quence of the inflammatory state of the skin the superficial 
lymphatic glands are more or less implicated, the swelling often 
persisting long after disappearance of the primary cause. En- 
largement of the epitrochlear glands — just above the internal ^^^°^^ 



tion from 

simple 

pemphigus. 



Enlarged 
epitrochlear 




Fig. 127. — Pemphigus Syphiliticus Involving Especiallv the Soles 
of the Feet. (Sheffield.) 

condyle of the hinnerus is especially common and of diagnostic 
importance. Special mention deserve also the syphilitic condylo- condylomata. 
mata, especially at the anus and female genitals. They usually 
begin as simple papules and from the eft'ect of irritating dis- 
charges undergo transformation into luxurant growths. 

With the aforementioned clinical findings in view, it requires 
no sage to solve the problem of diagnosis. Now, if the physician 
bases his judgment upon the symptoms presented, does not allow 
himself to be led astray by spurious histories (omnis syphiliticus 
mendax !), but goes right ahead and employs suitable antisyphilitic 
measures (see page 408). the chances of rapid improvement and 
ultimate recovery are ver}^ good indeed. Otherwise, the syphilitic 

26 



402 COMMUNICABLE DISEASES. 

process often violently runs its destructive course, attacks one 
structure after another, one organ after the other, crippling the 
hapless infant for hfe, if it unfortunately survives. 

The osseous system hardly ever escapes involvement. As in 
fetal syphiHs (q.v.), the syphiHtic bone affection consists prin- 
chondritTs' cipally of an osteochondritis and sometimes caries and necrosis. 
There is an overgrowth of the cartilage between the epiphyses and 
diaphyses of the long bones, often giving rise to painful circular 
swelling in the epiphyseal region and separation of the affected 
limb (spontaneous fracture), with consecutive loss of power 
paralysis" (Parrot's pseudoparalysis). This process is usually (but not 
invariably) unilateral — herein differing from rachitis in which 
the epiphysitis is almost always bilateral. The skull presents 
^?o^des^ enlargements (Parrot's nodes) of the parietal eminences and 
a buffer-like bossing of the frontal bone which is generally 
designated as "hot-cross-bun" tumors. Occasionally the frontal 
bone appears either unduly convex and prominent (front 
forehead. Olympian) or keel-shaped, with a central ridge and lateral flat- 
tening. These syphilitic manifestations are often associated with 
craniotabes, delayed (or premature) closure of the fontanelles 
and great brittleness of the milk-teeth. 

The liver is often the seat of cellular infiltration (interstitial 
Hepatitis, hepatitis) or variously sized gummata, rarely large enough to be 
visible to the naked eye. The liver is enlarged, hard and uneven 
to touch, but palpable through the abdominal wall only in 
advanced cases. Marked syphilitic changes in the liver fre- 
quently give rise to icterus, acholic stools, and bile-colored urine. 
On the other hand, mild forms of the disease are usually entirely 
free from symptoms. 

Next to the liver the spleen is most prone to suffer in syphilis. 
Perisplenitis. It is enlarged and readily palpable through the abdominal wall. 
Splenomegaly being of so common occurrence in early childhood, 
it is difficult to determine how much of this phenomenon is due 
to the syphilitic process and how much to other causes, especially 
rachitis. The younger the infant (under six months), the greater 
the probability of the perisplenitis being syphilitic in nature, 
especially if the splenomegaly be associated with other syphilitic 
symptoms, such as "Parrot's nodes," condylomata, and ozena. 

Syphilis of the pancreas is not demonstrable during life, but 
it has repeatedly been proven, by post mortem, that the pancreas 
is affected in a way very similar to that of the spleen. 



SYPHILIS. 403 

The intestines are but rarely affected. Intestinal syphilis is 
manifested chiefly by ring-shaped indurations of the muscles and 
mucous membrane, leading to gradual constriction of the intes- paSes.^^ 
tinal lumen. The pathologic process resembles that of "Peyer's 
patches." 

Clinically intestinal syphilis gives rise to protracted diarrhea, 
often with fatal termination. 

Syphilitic changes (perivascular cellular infiltration; gum- 
matous deposit) are occasionally met also in the kidneys and 
suprarenals (paroxysmal hemoglobinuria; nephritis), in the heart urogenital 
(symptoms of myocarditis), in the lungs (pneumonia with slow fung^^' 
course; spirochsete in the sputum), in the thyroid gland thymus. ^^ 
(struma), in the thymus (cyst, or abscess), in the testicles (often 
greatly enlarged; hydrocele; arrested development), and in the 
ovaries (demonstrable post mortem; sometimes by rectal, biman- 
ual examination during life). 

Arteritis and periarteritis, gummatous deposits and sclerosis 
occasionally occur in the brain and spinal cord as in the other 
organs of the body, and the concomitant symptoms vary with the 
seat of the lesions. Chronic meningitis and hydrocephalus are chronic 

. . . . meningitis. 

not rarely of syphilitic origin, and epilepsy, idiocy, local paralysis 
of the extremities and of the eye muscles, blindness, disseminated 
sclerosis and tabes dorsalis have occasionally been traced to con- 
genital syphilis. Also cases of syphilitic encephalitis are on Encephalitis 
record. The resemblance between syphilis of the nerve system 
and tuberculosis should not be lost sight of. 

As already suggested the diagnosis of syphilis is very easy 
when the aforementioned symptom-complex is in full bloom. 
Cases, however, are not rarely encountered which are apt to test 
the skill of even the best diagnostician. I am referring espe- ^^^^^^ 
cially to those which either run a very latent course from the 
beginning, or do so after a few weeks' antisyphilitic treatment. 
Every bit of information as to the past personal (''snuffles," erup- 
tion, etc.) and family history (miscarriages; persistent sore 
throat in the mother or father!) should be utilized to arrive at a 
correct conclusion. Old cracks and scars at the anus, mouth, 
nares, etc. ; dark, mottled skin ; old marks of healed ulcers in the 
mouth and throat ; persistent ozena ; intractable intertrigo, etc. ; 
excessive brittleness of the milk-teeth — should all be carefully 
looked into, and where doubt still exists the patient be given the 
benefit of the doubt and actively treated for syphilis — the rapidity 



Diagnosis in 

latent 

cases. 



404 COMMUNICABLE DISEASES. 

of response to treatment at the same time serving as a differential 
Therapeutic point of diagnosis (therapeutic test). 

Wherever possible laboratory tests should supplement ordi- 
nary clinical examination. Of these Wassermann's serum diag- 
^^^reaSfoif ^osis of Syphilis is deserving of special consideration (see page 
■ 98). 

With estabhshment of the diagnosis of syphilis, the remedies 
to be employed to eradicate the disease fortunately leave no room 
for speculation. The treatment which will be fully outlined in 
the subsequent pages (see page 408) should be carried out ener- 
getically and systematically and continued until apparently every 
vestige of the disease has been completely removed. 

Inadequate treatment not only greatly mars the prognosis of 
syphihs as to life and recurrences, but only too often is respon- 
sible for the development of the symptom-complex which is 
syp^tift' generally described as "parasyphilis." This group of syphiHtic 
manifestations (syphilitic cachexia) consists of extreme debility, 
marasmus (especially in artificially fed), profound anemia 
(pseudoleukemia), obstinate gastrointestinal and bronchial 
catarrh, otitis (deafness), disposition to rachitis, cretinism and 
idiocy, and lowered power of resistance to divers acute infectious 
Higii diseases. While the mortality of the carefully treated syphilitics 
is comparatively small, those who are carelessly managed often 
succumb to intercurrent diseases, even of the most trifling char- 
acter, not rarely die suddenly without apparent cause, and if they 
survive, remain decrepit for life, and a source of horrible misery 
to future generations. - 

SYPHILIS HEREDITARIA TARDA S. LATA. 

Late hereditary syphilis attacks the offspring of syphilitic 
parents at any period between early childhood and adolescence. 
The children thus affected may or may not have shown manifes- 
tations of congenital syphilis during intra-uterine life or soon after 
birth. The symptoms, however, are more pronounced in those 
who had been treated inadequately or not at all. Late hereditary 
Corresponds syphilis essentially corresponds to the tertiary stage of acquired 
tertiary syphilis. Like the latter it shows a predilection for the osseous 
system ; but no structure or organ of the body is exempt from its 
destructive effects. 

As we will presently demonstrate, the lesions of late 
hereditary syphilis may be numerous and grave, but not always 



mortality. 



stage. 



SYPHILIS. 



405 



Triad of 

syphilis. 



strictly pathognomonic of this disease. There is, however, one 
group of syphiHtic manifestations, which, if present, invariably 
betrays the presence of a syphilitic taint. 

This symptom-complex is generally described as the "triad of 
syphilis" and consists of the following phenomena : — 

1. The so-called Hutchinson teeth. The characteristic teeth 
of syphilis are the two upper central incisors of the permanent 
set. The teeth are chalky, ill-developed, small, and irregularly 
placed. They taper from the free border to the base — hence the 
term ''screwdriver teeth" — and present a broad, semilunar notch 
in the center of the edge. They should not be confounded with Hutchinson 
the brittle and decayed milk-teeth observed in infantile syphilis 
or rickets, and the irregularly implanted teeth associated with 
deformed palate or dental arches. 



teeth. 




Fig. 128. — S3-philitic, "Hutchinson Teeth." Xote semilunar notches 
in central incisors. (Sheffield.) 



2. Interstitial keratitis. The almost invariably symmetrical 
affection begins with corneal haziness which rapidly increases 
until the entire cornea is in a condition of partial opacity resem- 
bling "ground-glass." It is associated with congestion of the 
ciliary region and slight inflammation of the conjunctiva, and in 
severe forms of the disease, with iritis, retinitis and choroiditis. 
In addition to the corneal gray-colored patches, abruptly 
margined, crescentic patches of salmon tint are often present on 
the corneal surface, this sign of vascularity not rarely spreading 
over the whole cornea and giving rise to a deep plum tint of 
purple redness. Excessive lacrimation and photophobia prevail 
from the start, in marked cases reducing the patient to a state 
of practical blindness. The disease runs a very slow course, 
from about three months to a year or longer, and when it sub- 
sides leaves behind more or less marked corneal opacity and 
visual impairment. 

3. Deafness. This condition is not accompanied by any 
inflammatory symptoms. It is caused by syphilitic involvement 
of the labvrinth (often of both ears). The deafness verv rarelv 



Keratitis. 



Deafness. 



406 



COMMUNICABLE DISEASES. 



clears up spontaneously and entirely. On the contrary, even 
Permanent Under active treatment permanent defective hearing is the rule. 
This peculiar form of deafness often precedes or follows the 
attack of keratitis and is gradual in its development. 



deafness. 




Fig. 129. — Syphilitic Osteoperiostitis of the Tibiae. "Saber-shaped 
Deformity." Note also deformed bridge of nose. (Sheffield.) 



Osteo- 
periostitis. 



The bone lesions of syphilis consist of an osteoperiostitis, 
or soft gummatous periostitis, especially of the tubular and 
cranial bones. The most frequent seat of the disease is the tibia ; 
then follow the ulna and radius, the humerus, femur, clavicle, 
the bones of the skull, the phalanges and sternum. Syphilis of 
the shaft of the tibia usually gives rise to a characteristic ''saber- 



SYPHILIS. 407 

shaped" deformity of the tibia, the so-called ''tibia en lame de f^^^^^ 
sabre." It differs from the rachitic deformity of the tibia by its deformity, 
crest being rounded (in rickets it is sharpened) and its internal 
and external surfaces convex (in rickets they are flat or concave). 

The cranial bones are affected in a manner similar to that of 
syphilis neonatorum (see page 402). Ulceration of the soft palate 
and perforation of the hard palate and nasal bones with secondary 
*'saddle-shaped" deformity of the nose are of common occurrence, shaped" 

SyphiHs of the phalanges (syphiHtic dactylitis) is character- 
ized by a puffy, fusiform, or spindle-shaped swelling. It affects Dactylitis, 
the fingers more often than the toes. The inflammation may 
begin either in the connective tissue and ligaments or in the 
periosteum and bone. If left alone the disease progresses rapidly 
and leads to protracted osteomyelitis with ankylosis, shortening 
and permanent deformity of the affected parts. Syphilitic 
dactylitis differs from the tuberculous variety, which it greatly tion from 
resembles, by its being less common, often symmetrical and 
accompanied by other syphiHtic lesions. 

Occasionally the joints participate in the syphilitic process, 
but the affection is rarely of serious nature. It essentially con- 
sists of a recurrent synovitis with thickening and ankylosis, and Synovitis, 
may readily be mistaken for articular rheumatism. The absence 
of fever and redness and the history of syphilis usually clear up 
the diagnosis (see page 419). 

The skin sometimes presents subcutaneous gummata which subcutaneous 

^ ^ gummata. 

when neglected have a great tendency to break down and to form 
large phagedenic ulcers. They are most frequently met on the 
face and upper part of the thighs or legs. They promptly yield to 
energetic antisyphilitic treatment — a feature to be borne in mind 
in the differential diagnosis between syphilitic and tuberculous 
ulcers. 

Similar ulcerating gummata are not rarely found in the 
mouth, nose and throat. If not promptly arrested they are rapidly 
destructive and may occasion extensive disfigurement. 

The lymphatic system and the viscera, especially the liver and 
spleen, rarely fail to show late syphilitic manifestations. The 
latter are essentially identical with those described in connection 
with congenital syphilis neonatorum (see page 402). 

Finally, mention may be made of the tendency of late 
syphilis to arrest the development of the child's body and mind. 
Dwarfism and infantilism are not rarely traceable to this baleful infantilism. 



408 COMMUNICABLE DISEASES. 

cause. Indeed, appreciating the gravity, multiplicity and com- 
plicacy of the syphilitic lesions, it is rather surprising that the 
aforementioned bodily and mental deteriorations are not more 
rampant. 

Notwithstanding the apparent explicitness of the symptoma- 
tology, the diagnosis of late hereditary syphilis is by no means 
a simple proposition. It is especially difficult in cases complicated 
by intercurrent diseases, e.g., tuberculosis or rickets. 

The specific history; the simultaneous occurrence of lesions 
in various parts of the body ; the tendency of the bone lesions to 
gnomonic be Symmetrical; the appearance of the manifestations very fre- 
quently in the midst of apparently perfect health, and, finally, 
the quick response to antisyphilitic treatment — are more or less 
decisive in the diagnosis. Of course, all doubt is removed by 
positive microscopic or bacteriologic findings, especially serum 
diagnosis. 

ACQUIRED SYPHILIS. 

Newly born infants may acquire syphilis either intrapartum, 
by coming in contact with a chancre in the parturient canal, or 
while nursing of the breast of a woman (mother or wet-nurse) 
in the contagious state of syphilis. The disease may further 
be acquired by infants and older children practically in the same 
manner as by adults. It is well to remember that newly born 
Coiitagu)us- infants with secondary symptoms of syphilis may transmit the 
syphilis disease to healthy people through fondling, the use of articles 

leonatorum. j f f ... . 

coming in contact with syphilitic lesions, etc. I have now in 
mind two older, previously healthy brothers who have in this 
manner acquired syphilis from a newly born syphilitic child. 

The course of acquired syphilis in children is identical with 
that observed in adults, except that it is prone to be more rapid 
and violent. 

Treatment of Syphilis. — The treatment of syphilis is alike 
in both forms of the disease — inherited (early and late) and 
acquired. It should be begun with as soon as the diagnosis has 
been established. Temporizing is often fatal. Mercury in some 
Mercury fo^^i IS the ouly remedy that is certain in its results, and should 
be administered continuously until every vestige of the disease 
has apparently disappeared, and then given at intervals of from 
two to six weeks for a total period of from two to three 
years. Calomel is the preparation par excellence. One-tenth to 
one-fourth of a grain twice (to an infant) or thrice (to an older 



SYPHILIS. 



409 



The iodids. 



Salivation. 



Keratitis. 



Osteitis. 



child) will usually suffice. Now and then we may also employ 
sodium iodid (half a grain for every year of the child's age) 
three times a day, or the syrup of the iodid of iron (three drops 
for an infant under one year, five drops for two years, and ten 
drops for over five). To hasten saturation of the system with 
the mercury, we may, in addition, resort to mercury inunctions. 
From 10 to 30 grains of mercurial ointment may be rubbed in 
once a day alternately into the axilla, groin, abdominal wall, calf- 
muscles, and loins. To prevent excessive salivation the oral 
cavity should twice daily be washed with a 2 to 5 per cent, solu- 
tion of chlorate of potash or tincture of myrrh. Syphilitic ulcers Ulcers, 
should be cauterized with nitrate of silver solution (3 per cent, 
to 10 per cent.). Keratitis calls for local use of atropin sufficient 
to keep the pupils widely dilated, hot poultices (by means of moist 
hot cloths), occasional dusting of calomel over the corneal ulcers, 
protection from bright light (dark room or smoked eye-glasses), 
and, of course, internal administration of mercury and the iodids. 
The great majority of cases of osteitis yield promptly to consti- 
tutional treatment, but where necrosis is pronounced the manage- 
ment must follow ordinary surgical lines. Persistent condylomata Condylomata, 
will rapidly disappear after a few applications of a 5 per cent, 
salicylic-resorcin-collodion solution, or occasional painting with 
caustics. Onychia and paronychia should be treated by local onychia, 
bichlorid baths (1:2000), once or twice daily, and dusting with 
calomel 1 part, gum arabic 1 part, and stearate of zinc 20 parts. 
Indurated lymph glands usually yield to potassium iodid oint- 
ment, while suppurating glands require surgical interference. 

The general health of the patient should not be lost sight of. 
Other conditions being favorable, a syphiHtic mother should nurse 
her syphilitic child. This being impossible, the infant should be 
put on properly modified cows' milk, or on the breast of a wet- 
nurse who emerged from an attack of syphilis without serious 
consequences. In older children also particular attention should 
be paid to good nutrition. The tendency of rickets complicating 
syphilis should be borne in mind. Hydrotherapy, plenty of fresh, 
pure air, and general tonics are essential to success. 

Within the last few months marvelous cures have been re- 
ported from the hypodermatic use of dioxydiaminoarsenobenzol 
(the mysterious "606" of Ehrlich and Hata). The remedy is 
dissolved in commercial soda lye by rubbing in a mortar; glacial 
acetic acid, drop by drop, is then added, obtaining a fine yellow 
precipitate. This is suspended in distilled water and the reaction 

26a 



Adenitis. 



Maternal 
nursing. 



410 COMMUNICABLE DISEASES. 

of the liquid is made exactly neutral to litmus paper. The sus- 
pension (containing from 2 to 5 grains of the remedy) is slowly 
injected below the shoulder blade or in the gluteal region. One 
injection is claimed to arrest the disease. ^ 

MALARIA 

(Febris Intermittens. Febris Remittens, -ffistivo-autumnal). 

Malaria is endemic in the greater portion of the inhabited 
world, and is most prevalent in moist tropical regions. No age 




Fig. 130. — Malaria Plasmodia ; Tertian Type. Plehn-Chenzinsky's 
Stain. X 1000. {Lenharts and Brooks.) 

is exempt from this disease. The exciting cause of malaria is the 
hematozoon of Laveran conveyed to the human body principally 
sionThrough ^y the bite of the Anopheles mosquito which has previously 
™°^bites! sucked the blood of a malarial patient and has acted as an inter- 
mediate host for the malarial parasite. The hematozoon enters 
the blood-corpuscles and, after undergoing the different stages of 
development, the blood-current — at this time giving rise to the 
characteristic chill or paroxysm. Depending upon the period of 
maturity and species of the Plasmodium, the febrile attack may 
Quotidian, occur cvcry day (quotidian) ; every two days, going on the third 
^^'^^qlTanan (tertian) ; every three days, going on the fourth (quartan) day; 
or may be more or less continuous with daily remissions (remit- 
tent or estivo-autumnal fever). 



types. 



1 Syphilitic newly born infants who are nursed by their mothers (or 
syphilitic wet-nurses) will derive the full benefit of the remedy by ad- 
ministering it to the mother. In fact, this method of treatment is greatly 
to be preferred to direct treatment of the baby. 



MALARIA. 



411 



INTERMITTENT FEVER. 

This form of malaria is characterized by the occurrence, at 
regular intervals, of paroxysms divided into four stages — pre- 
monitory, chill, fever, and the sweat. During the premonitory 
stage the patient complains of headache, lassitude, and nausea; 
he vomits, yawns, is irritable and drowsy. Suddenly he is seized 
with a feeling of cold — the chill. The features become pinched, 
the lips blue, the skin cool and rough (cutis anserina) ; he shivers 
and shakes, and his teeth chatter while the thermometer in the 
axilla or rectum shows a decided rise of temperature. These 
phenomena may continue for from a few minutes to an hour or 



Chil 




Fig. 131. — Temperature Chart of Quotidian and Tertian Ma- 
larial Fever in a Child 22 Months Old. The fever changed from 
quotidian to tertian on administration of a few large closes of 
quinine. (Sheffield.) 

longer and are then gradually replaced by those of the hot stage, 
i.e., hyperpyrexia, flushed face, headache, full pulse, intense 
thirst, scanty urine, sometimes nausea, vomiting and severe 
nervous manifestations. The hot stage lasts from three to six 
hours or longer, and subsides gradually, being succeeded by more 
or less marked sweating, rapid defervescence and abatement of 
the other symptoms. The duration of the entire paroxysm is 
from six to twelve hours, after which time the patient is appar- 
ently well — until the return of a new attack, which, as already 
mentioned, may occur every day, every two days or three days. 

This description corresponds with the symptomatology of 
typical intermittent fever, uninfluenced by medication, as it occurs 
in children over ten years of age. It is thus identical with that in 
adults. In younger children the course of the paroxysms pre- 



Fever. 



Sweat. 



412 COMMUNICABLE DISEASES. 

Deviations sents numerous deviations. The prodromic and cold stages may 

infants. ^^ absent or of very brief duration. The chill may be replaced by 

grave nervous manifestations, such as convulsions, or be indicated 

Cyanosis. Only by cyanosis of the lips and the tips of the fingers and toes. 

Sweating is slight or absent, or may be well marked and continue 

until the subsequent paroxysm of fever. Young children are 

rarely entirely free from discomfort during the intermittent stage. 

As a rule, they are exhausted, restless, have no appetite, etc. 

^s^Sn. With repeated attacks of the fever there is marked swelling of the 

spleen and great diminution in the number of red blood-cells. 

In view of the aforementioned deviations from the typical 
course of the paroxysms, the diagnosis of intermittent fever in 
young children often presents great difficulties. It is apt to be 
mistaken for tuberculous (meningitis, lymphangitis, peritonitis, 
etc.) and pyemic (empyema, pyelitis, ulcerative endocarditis, 
otitides, etc.) processes, typhoid and influenza. A correct diag- 
nosis, however, can usually be arrived at by exclusion, always 
bearing in mind the facts that in malaria the plasmodium malarise 
or secondary pigmentation of the blood-cells is invariably present 
in the blood and that the course of the disease is greatly modified 
by full doses of quinine. The finding of an enlarged spleen (also 
liver) without a history of syphilis or rickets points to malaria 
of more or less prolonged standing, and a history of malaria is, 
of course, corroborative in the diagnosis. 

REMITTENT (^STIVO-AUTUMNAL) FEVER. 

This type of malarial fever is usually observed in temperate 
zones, principally in the autumn. In institutions where large 
numbers of children are congregated it may occur in epidemic 
form and lead to grave diagnostic errors. It usually sets in sud- 
denly with malaise and chilliness, followed by fever with exacer- 
bations and remissions, the temperature during the latter, how- 
ever, remaining constantly above normal. The other symptoms 
are very indefinite. As in all febrile diseases, anorexia, nausea, 
sometimes vomiting, headache, drowsiness and lassitude pre- 
dominate. In some cases gastrointestinal symptoms prevail, in 
others respiratory. But the cardinal manifestations of the affec- 
tion are the continued fever of from one to three weeks' duration 
with irregular remissions, palpable spleen, and the plasmodium 
malarise in the blood. Bearing these clinical symptoms in mind 
and those of the diseases suspected, there ought to be no difficulty 



MALARIA. 413 

in differentiating remittent fever from typhoid fever or protracted 
influenza — with both of which diseases it is most apt to be con- 
founded. The quinine test is not reliable in the remittent form 
of malaria. 

The prognosis of remittent fever is favorable, except for 
the tendency to recurrence at shorter or longer intervals and of 
ultimately becoming chronic. 

CHRONIC MALARIAL CACHEXIA. 

The diagnosis of this condition is often A'ery difficult, since its 
principal symptoms — anemia, debility, enlarged spleen and liver 
— are also pathognomonic of severe rachitis, pseudoleukemia, and 
similar wasting diseases. Corroborative data may be obtained 
from a history of previous attacks of either intermittent or re- pgj.io^j(, 
mittent fever or the occurrence of periodical headache, neuralgia, ^eadache, 

^ ' o ^ nematuria, 

dysentery or hematuria. One should be very cautious, however, ^^^• 
in making a hasty diagnosis of "malaria,'' unless there be ample 
reason for exclusion of the other affections and the therapeutic 
quinine test prove positive. 

Chronic malarial cachexia per se is not dangerous to Hfe, but 
is apt to prove so from its concomitant symptoms, such as pro- 
found anemia and amyloid degeneration of the viscera. 

Treatment. — As malarial fever is ordinarily contracted 
through the bites of mosquitoes, to prevent malarial disease, we destruction 
must either destroy the mosquitoes or aA'oid their bites. An °^ mosquitoes. 
eft'ort should be made also to isolate, by mosquito-netting, all cases 
of acute malarial disease, in order to deprive the mosquitoes of 
the infective material. Another very important measure is to 
prevent the breeding of the mosquitoes. ^Mosquitoes lay their 
eggs in water-barrels, pans, tin cans, pots, kettles, wells, springs, 
rainpools. cesspools, drainage traps, ponds — in short wherever 
stagnant water is found. AA'e have to see to it that all water 
receptacles are closely covered with thin, wire gauze, and that 
where drainage cannot be carried out, the surface of ponds, etc.. ^^^^^^^^ 
is covered with a film of kerosene oil. One ounce of oil to fifteen 
square feet of water will usually suffice. The oil must be re- 
newed about once a week during the mosquito season. A solution 
containing one pound of sulphate of copper and one pound of 
unslaked Hme in ten gallons of water will kill the mosquito 
larvae when added in the proportion of one of the solution to 
fiftv of the infected water. 



414 



COMMUNICABLE DISEASES. 



Quinine 
specific. 



White people settling in malarial tropical regions should not 
plant their houses near native settlements. 

Where the aforementioned prophylactic measures cannot prop- 
erly be enforced, resort should be had to the routine administra- 
tion of quinine during the mosquito season. 

Whether as a prophylactic or curative measure, quinine is 
the specific destructive agent of the malarial parasites. To obtain 
prompt results it should be given in full doses. Children tolerate 
relatively much larger quantities of quinine than adults. An 
By mouth, infant of two years requires about 15 or 20 grains a day until the 
attack is controlled and smaller doses after. For children unable 
to take quinine in capsules I prefer the newer "tasteless" quinine 
preparations, such as quinine ethyl carbonate, diquinine carbonic 
ester, etc., or administer (see page 116) the ordinary bitter quinine 
per rectum (quinine subsulph. gr. v in gij of water by means of 
colon tube). In cases of marked gastric irritabihty or in those 
very grave in nature or protracted in course, quinine may be 
employed in 5 gr. doses hypodermically. For this purpose 
bimuriate of quinine and urea, the hydrochlorosulphate, the 
hydrobromate, or the bisulphate may be used. Ugly sloughing 
which is apt to follow at the site of the injection may be pre- 
vented by cleanliness of the needle and skin and by throwing the 
solution deeply into the subcutaneous tissues and sealing the 
point of puncture with adhesive plaster. 

In protracted cases iron and arsenic (Fowler's solution) will 
be found useful additions to the quinine, and when there is a 
great tendency to recurrences, permanent residence in dry moun- 
tainous regions will sometimes remain the only curative measure 
at our command. 

R. Quinine ethyl carbonate, or diquinine carbonic ester... 3ss | 2 

Syr. simplicis q. s. ad §ij j 60 

M. Sig. : 3j every two to four hours for a child 3 years old. 



Per rectum. 



Hypoder- 
matically 



Iron and 
arsenic. 



I^ Quininae mur gr. xv 

Acetanilidi gr. vj 

Podophyllini gr. 



Ext. 



nucis vomicae 



g-r.i/i 



1 

0.4 
0.008 
0.016 



ft. 



caps, no XI J. 
Two capsules every three hours for a child 10 years old. 



I^ Acidi arseniosi gr. M.0 

Quininas mur 3ss 

Ferri sulph. ex gr. x 

Pulv. rhei gr. v 

M. ft. caps. no. xx. 

Sig. : Two capsules every six hours for a child 10 years old. 
malaria.) 



0.006 
2 

0.666 
0.333 

(Chronic 



RHEUMATISMUS ACUTUS. 415 

IJ Elixir ferri pvrophosphatis, quininas et strychninse 

(X. F.) ..'. Siss|45 

Syr. aurantii q. s. ad 5ii j | 90 

M. Sig. : 3j three times a day for a child 4 years old. (In convales- 
cence.) 

RHEUMATISMUS ACUTUS 
(Rheumatic Fever, Polyarthritis Acuta). 

Acute inflammatory rheumatism is an infectious disease with 
a specific predilection for the fibrous tissues and serous mem- 
branes. The muscular and neural structures, however, are not 
exempt from it. The discovery of the rheumatism-producing 

\Iicrobic 

micro-organism is a matter probably of the very near future. origin. 

Like other infectious diseases rheumatic fever is most prev- 
alent in certain climates and seasons of the year. It presents a 
prodromic stage of variable duration, which is characterized by 
chilliness, languor, etc. Like the eruptive fevers it is manifested 
by general febrile disturbances with local lesions. To a certain 
extent it is self-limited, since with exhaustion of the fertile soil in 
one place, the inflammation "jumps" to another place. It ordi- 
narily yields promptly to specific medication — in this respect, also 
resembling infectious fevers, e.g., malarial fever. 

After a brief prodromic stage, the symptoms of acute rheu- 
matism usually set in suddenly, with chills, rise of temperature, 
vomiting, and vague pain in several parts of the body. In very 
young children the onset is not rarely associated with cerebral 
symptoms, especially convulsions. Older children often complain throat, 
of sore throat, and in some cases articular swelling forms the 
first and principal manifestation of the aflfection. The disease 
once established differs in its symptomatology and course but 
little from that observed in rheumatism in adults, except, as will 
be seen later, that in children there is a great tendency toward 
cardiac complications, while the articular involvement is usually 
less pronounced. 

The joints of the knee, ankle, elbow and wrist are most com- 
monly affected, occasionally also those of the phalanges and hip. 
The articular involvement is accompanied by stiffness, slight red- rednelf' 
ness, swelling and excruciating pain, the latter especially on pj^^^^^ ^^' 
moving or handling the parts affected. The inflammation may 
abruptly cease at one or more joints and, as suddenly, attack 
others. During the acute stage the temperature ranges between 
102° and 104° F., and as the inflammation ''jumps" from joint 



416 



COMMUNICABLE DISEASES. 



Jumping to joint there is usually a sharp rise of temperature. Correspond- 
^to^jSnt! ingly the temperature falls with abatement of the local manifes- 
tations. The urine is usually scanty and high-colored, filled with 




Fig. 132. — Rheumatic Polyarthritis (2 years old). Note 
swelling of knees; tumefactions at right ankle and foot, effacing 
the normal bony prominences and the arch. (Sheffield.) 



Rarely- 
sour 
sweat. 



urates, and occasionally contains traces of albumin. The charac- 
teristic sour (lactic acid) sweats observed in adults are much less 
pronounced in children. 

There is no definite limitation to the duration and course of 
the affection. Mild cases, after pursuing a few days, may either 



RHEUMATISMUS ACUTUS. 



41' 



recover entirely or enter into a subacute, afebrile stage, and for 
weeks and months be manifested by vague articular and muscular 
pain, and ultimately end either in complete recovery, or leave 
behind some form of subacute or chronic heart disease. Indeed, 
it is usually in such cases that the heart affection is overlooked, 
iind accidentally discovered some time (years!) later, without 
being able to disclose a rheumatic history. Severe cases may run 
a febrile course of from three to five weeks, and if left untreated, 
sometimes, as many months. It is well to remember that the 
gravity of an attack is not always commensurate with the severity 
of the articular involvement. In quite a number of cases endo- 
carditis or pericarditis, or both, may predominate while the other 
symptoms are barely noticeable. Hence the importance of a 
routine and careful examination of the heart of children suffer- 
ing from rheumatic and ''growing" pain, or chorea. The latter 
disease, by the way, is closely allied to, and may precede, accom- 
pany or follow rheumatism in its various forms. (See ''Chorea.") 

The earliest symptoms of rheumatic endocarditis are increase 
of frequency and intensity of the heart-beat and precordial pain. 
This is soon followed by the usual physical signs of endocarditis 
— those of mitral regurgitation predominating. Endocarditis 
forms the most frequent (in about 60 per cent.) complication of 
inflammatory rheumatism and usually sets in within the first ten 
days from the onset. 

Pericarditis is observed only in about 10 per cent, of the 
cases, and somewhat later than endocarditis. It is manifested by 
a serous exudation which may rapidly, and unnoticeably, dis- 
appear, or persist and lead to pericardial adhesions and their 
accompanying more or less grave sequelae. 

Less frequent complications are pleuritis and pneumonitis. 
Both of these affections are ordinarily limited to the left side. 
The pleuritic effusion may be serous or serofibrinous and is most 
frequently associated with pericarditis. Of still less frequent 
occurrence are peritonitis and nephritis. The abdominal pain, 
however, not infrequently complained of by children during an 
attack of rheumatism is usually due to muscular hyperesthesia 
and not to peritoneal involvement. 

As in adults, rheumatism of children may also affect the 
muscles. Rheumatic torticollis is especially common, and in 
severe cases is apt to be mistaken for cervical spondylitis. 
Muscular rheumatism affecting the muscles of the lumbar region 

27 



Heart dis- 
ease often 
overlooked. 



Rheumatism 
and chorea. 



Endocarditis. 



Pericarditis. 



Pleuritis and 
pneumonia. 



Peritonitis 

and 

nephritis. 



Muscular 
rheumatism. 



Torticollis. 



418 



COMMUNICABLE DISEASES. 



Resemblance 
to spondy- 
litis and 
coxitis. 



Differentia- 
tion from 
osteomye- 
litis. 



Patho- 
gnomonic 
symptoms. 



may resemble lumbar spondylitis ; and that of the leg may give 
rise to symptoms (pain on motion, lameness, stiffness, etc.) 
simulating coxitis. As previously mentioned rheumatism of the 
abdominal muscles may simulate peritonitis, while rheumatism of 
the intercostal muscles may be mistaken for dry pleurisy. In 

all these cases a diagnosis 
can usually be arrived at 
by bearing in mind the 
pathognomonic symptoms 
of the affections the mus- 
cular rheumatism resem- 
bles, and the facts that 
the latter promptly yields 
to the salicylates, and that 
there, as a rule, is a his- 
tory of involvement of 
other groups of muscles. 
Rheumatism ma}^ also 
affect the periosteum and 
give rise to thickening 
of the underlying bone, 
which condition, with the 
accompanying pain and 
fever, may simulate incip- 
ient osteomyelitis. From 
what has been said, it can 
readily be seen that the 
diagnosis of rheumatism 
in its various phases is far 
from being easy. 

Moreover, articular 
rheumatism may also be 
mistaken for: Syphilitic, 
gonorrheal, tuberculous, 
and the so-called septic 




Fig. 133. — Rheumatic Torticollis 
in a Child 6 Years Old, which 
greatly resembled Cervical Spon- 
dylitis. (Sheffield.) 



arthritides, scurvy, and its allied affections and osteomyelitis. 

In our endeavor to differentiate rheumatism from the divers 
forms of articular and periarticular inflammations we must bear 
in mind that rheumatism is a primary febrile affection, as a rule, 
sudden in development ; that its inflammatory process is transient, 
and its localization multifarious and rapidly shifting, and, finally. 



RHEUMATISMUS ACUTUS. 



419 



that its course is promptly and often permanently influenced by 

the salicylates. Differential 

Epiphysitis Syphilitica. — Develops slowly, in the first few 
months of life — rather exceptional for rheumatism — in associa- 

. . . . ...... -^ Slow onset, 

tion With Other symptoms ot congenital syphilis. It runs an afebrile 
afebrile course and yields promptly to antisyphilitic medication. 
Arthritis Heredosyphilitica (Tarda). — Develops gradually, 




Fig. 134. — Same case as Fig. 133. Three weeks later. (Sheffield.) 



Mild sub. 
jective symp- 



and affects principally one or both knees. It is usually associated 
with other syphilitic symptoms, especially parenchymatous 
keratitis. As a rule, the subjective disturbances are incongruous 
with the severity and extent of the local signs, and the arthritis *°°^^' 
is but rarely accompanied by inflammatory symptoms. It yields 
promptly to antisyphilitic medication. Puncture of the swelling spirocha?te. 
reveals serofibrinous fluid and not rarely the spirochaete. 

Arthritis Gonorrhoeica. — It occurs as a complication of 
gonorrheal ophthalmia, urethritis or vulvovaginitis. It is most Gonorrheal 
frequently limited to one knee, more rarely to both knees, or the 
maxillary or sternal articulations, and is accompanied by pro- 
nounced inflammatorv local and o-eneral svmDtoms. The articular 



420 



COMMUNICABLE DISEASES. 



Atrophy. 



Tuberculin 
test positive. 



Secondary. 



Hemor- 
rhages. 



Different 
localization 
of swelling. 



Marked 
leucocytosis. 



Prognosi 



Rest in bed. 



involvement is more lasting than that of acute rheumatism, and 
resists antirheumatic measures. 

Arthritis Tuberculosa. — It develops gradually, usually 
remains limited to one joint, and resists antirheumatic treatment. 
Atrophy of the affected limb sets in early, and an X-ray examina- 
tion often shows involvement of the bone. Tuberculin reaction 
often positive. 

Arthritis Septica. — Septic or infective arthritis arises 
secondarily to sepsis {e.g., purulent arthritis, in sepsis neona- 
torum) or acute infectious diseases, such as typhoid fever, 
influenza, pneumonia, diphtheria, scarlatina, etc. The history is 
the most reliable clue in the diagnosis, and the finding of the 
streptococcus, pneumococcus, etc. in the seropurulent fluid 
obtained by exploratory puncture of the swelling is decisive. 

Scorbutus (Barlow's Disease), Purpura Hasmorrhagica and 
Hemophilia (with sanguineous efl-usion into the joints) also 
may be mistaken for acute articular rheumatism. In the hemor- 
rhagic diseases, however, there are hemorrhages from and into 
other parts of the body. The articular swelling is not as evanes- 
cent. Fever is usually absent or slight. Furthermore, Barlow's 
disease is observed in very young infants, who are rarely attacked 
by rheumatism. Antirheumatic treatment is futile. 

Osteomyelitis. — The swelling does not appear until a few 
days after the onset of the disease, and has its center, not opposite 
the joint, as in articular rheumatism, but above or below, opposite 
one or other of the epiphyses of the bones entering into the forma- 
tion of the joint. In advanced cases the swelling extends along 
the shaft to a variable distance. In contrast to osteomyelitis 
rheumatism is rarely limited to a single joint, and its swelling 
never suppurates. Leucocytosis is absent in rheumatism, and, as 
a rule, marked in osteomyelitis. A skiagraph is helpful in the 
differential diagnosis. 

Rheumatic fever per se is very rarely fatal, but only very few 
patients emerge uninjured from a severe attack of rheumatism. 
In probably two-thirds of the cases some form of heart-disease 
is acquired which sooner or later manifests evidence of its 
destructive character. This obtains particularly in recurrent 
rheumatism as well as in cases improperly cared for as regards 
rest and specific medication. 

Rest in bed is the most important therapeutic measure in the 
prevention of grave complications and sequelae, and should be 



RHEUMATISMUS ACUTUS. 421 

enjoined at least during the febrile course of the disease. Medi- 
cinally the salicylates act specifically in all acute rheumatic con- ^ ^^^ ^ ^^' 
ditions and their administration should be continued until every 
vestige of the disease has disappeared. In the beginning the 
salicylates should be pushed to their full tolerance — say one grain 
of the sodium salicylate for every year of the child's age, every 
two hours, until the acute symptoms have been arrested, then 
every four or six hours according to indications. With the 
appearance of cardiac complications the iodids, in small doses, lodids. 
should be added, and if necessary also digitalis. For the relief 
of articular pain and swelling the joint should be enveloped in 
absorbent cotton wrung out of a warm saturated solution of 
bicarbonate of soda. The compress should be covered with oiled Compresses, 
silk and flannel bandage and changed every two to four hours. 
When the pain is very acute I found the following very service- 
able : — 

I^ Olei gaultheriae, 
Guaiacolis, 

Ichthyolis aa 3ss I 2 

Adipis lanse Sj | 30 

Sig. : Apply gently twice a day, and cover with flannel bandage. 

Acute rheumatism being an infectious disease, I have no faith 
in "mathematical dietetics" as a cure of the disease, hence do not 
employ any specific dietary, but limit the diet to a so-called ''fever Fever diet. 
diet" during the febrile stage of the disease and to easily digestible 
food of all sorts later. This has the advantage of maintaining 
the nutrition of the patient who at best is weak and anemic. The 
prolonged use of the iodid of iron and cod-liver oil is always in on. ' 
order in the convalescent stage, and a sojourn in a dry and high 
inland resort will prevent recurrence and chronicity. 

B Natrii salicyl 3jj_ | 8 

Mist, rhei et sodse 3iij | 12 

Aq. destil q. s. ad H.iij | 90 

M. Sig. : 3j every two to four hours for a child 4 years old. 

^ Antipyrinse 3ss | 2 

Natrii salicyl 3iss 6 

Caffeinae natrii benzoatis gr. xvj 1 

Syr. simplicis 3iv 16 

Aq. destil q. s. ad f Bij 60 

M. Sig. : 3j every six to twelve hours for a child 4 years old, for 
quick relief of pain. 

I^ Olei gaultherise 3j | 4 

Ft. caps. no. xij. 

Sig. : One capsule every four to six hours for a child 6 years old. 
(For subacute rheumatism.) 



422 COMMUNICABLE DISEASES. 



RHEUMATISMUS CHRONICUS. 

Chronic rheumatism in children is very rare. As in adults it 
may supervene after recurrent attacks of acute or subacute 
rheumatism, or, very exceptionally, it may develop primarily. In 
either case the local manifestations are clinically alike, and consist 
of gradual enlargement of the affected joints, painful and 
hindered motility, ankylosis, and deformity of the bones at the 
articulations. The course of this form of rheumatism, though 
very protracted, and extending over a period of years, is usually 
not as slow as in adults. It eventually leads to crippling of the 
patients, and fatal termination either from exhaustion or second- 
ary tuberculosis. 

Chronic articular rheumatism may be confounded principally 
with syphilitic and tuberculous affections of the joints. Syphi- 
litic arthritis is usually accompanied by other syphilitic symptoms. 
Differentia- especially keratitis, and ordinarily yields to antisyphilitic treat- 
syphiiitic ment. The differentiation between simple chronic arthritis and 

and tuber- . . . . ^ , . . , 

cuious tuberculous jomts is quite difincult, since, as previously mentioned, 

arthritis. J n ^ > f j 

the latter may follow upon the former. However, the absence 
of temperature and failure to obtain a positive tuberculin reaction 
speak in favor of chronic non-tuberculous arthritis. The finding 
of a tuberculous exudation in the affected joint, of course, is 
decisive in the diagnosis. 

As the prognosis in protracted cases is very bad, active treat- 
ment should be begun with early and not too rapidly discontinued 
treat- in disgust bccausc of more or less persistent failure to effect a 
cure. The salicylates with small doses of sodium iodid internally 
and pure ichthyol externally should be given a thorough trial. 
Where stiffness and swelling of the joints prevail, daily gentle 
massage preceded by a hot local bath and followed by hot. moist 
compresses often works wonders. Passive motion should be 
practised early and where the contractures are very pronounced 
one should not hesitate to reduce the same under anesthesia and 
proceed with the treatment just outlined. Concomitant acute 
symptoms should be treated in the same manner as in acute 
rheumatism, and when there is reason to believe that the diseased 
strict diet. Condition is the result of faulty metabolism (intestinal intoxica- 
tion or uric acid diathesis?) the dietary should be regulated 
accordingly (exclusion of meats, acids, liquors, etc.). 



Persistence 
in 

ment. 



RHEUMATISML'S XODOSUS IXFAXTILIS. 423 

B Xatrii iodidi gr. xv | 1.0 

Ext. hyosciami ti gtt. \ j | 0.4 

X'atrii salic>-l 5j ■ 4.0 

Syr. sarsaparillae: comp jj | 30.0 

Aq. destil q. s. ad fsiij 90.0 

M. Sig. ; oij even,- four hours for a child 6 vears old. 



STILL"S DISEASE. 

This attection generally sets m during the hrst three or four 
years of life, and attacks girls more frequently than boys. It is 
characterized by gradually developing stiffness and enlargement Gradual 
of several joints, beginning with the knee, wrists and cervical Iniarjement 
vertebrae, and gradually extending to the lingers and toes. It °^ ^<'^^*^- 
differs pathologically from rheumatoid arthritis or tuberculosis 
in that it is free from destructive or proliferating processes of 
the bony structures. The enlargement of the joints is due purely 
to thickening of the soft tissues. Aside from the articular in- 
volvement Still's disease is characterized by a more or less marked 
enlargement of the lymphatic glands f axilla r}-. cenacal and adenitis. 
mesenteric) and of the spleen. It is occasionally associated with 
a slight rise of temperature, and shows a tendency to pericardial 
and pleural adhesions. 

It is a very chronic, incurable affection of unknown etiolog}-. 
Its progress may be partially arrested by the therapeutic measures 
outlined under "chronic rheumatism" (q. r.). 



RHEUMATISMUS NODOSUS INFANTILIS. 

ERYTHEMA NODOSUM. 

PELIOSIS RHEUMATICA (PURPURA RHEUMATICA). 

These three distinct diseased conditions are grouped together 
to facilitate their identification. They have several symptoms 
in common, and bear a close resemblance to rhetmiatism. Their lauon to 
true nature, however, is a matter of conjecture, and with our 
present ignorance as to the identitv" of the specific rheumatic 
germ there are no means of corroboration or of contradiction of 
any of the numerous assimiptions advanced by different 
authorities. 

1. RHEUMATISMUS XODOSUS INFANTILIS. 

It is peculiar of early childhood and occasionally follows a 
protracted or recurrent attack of rheumatism., especially in asso- 



424 COMMUNICABLE DISEASES. 

ciation with grave cardiac manifestations. It is characterized by 
the (often symmetrical) appearance, chiefly about the joints and 
near Joints! the tcndon insertions, of several nodules (noduli or osteomata 
rheumatici) which grow to a perceptible size, and then either 
undergo regressive, fatty metamorphosis and absorption, or 
persist, become calcified and acquire a bony consistence. The 
nodules (exostoses) vary in size from a small pea to a plum, and 
in number from one to a hundred. They are at first soft, flat 
and painful or tender to the touch, and later they become harder 
and rounder, resembling the fibromatous and osteomatous growths 
observed in ''myositis ossificans" and in "multiple exostoses" 
(q.v.). Treatment, antirheumatic. 

2. ERYTHEMA NODOSUM. 

Until recently this affection has been looked upon as a skin 
disease pure and simple. The sudden appearance, the rise of 
temperature, the self-limited course, and its association with 
more or less marked constitutional symptoms and occasionally 
grave complications (principally rheumatic pain, bleeding from 
mucous membranes and heart trouble) stamp it, however, as an 
acute infectious disease of obscure etiology. Locally it is char- 
acterized by the appearance, chiefly on the anterior portion of 
nodules in the lowcr Ics^s and forearms, of from a pea- to a walnut-sized, 

front of f . . 

lower legs pale-red painful nodules which at first resemble contusions 

and fore- ^^ ^ ^ ^ 

arms, (erythema contusiforme). They gradually disappear, changing 
in color to bluish, green and yellow within from two to three 
weeks, as a rule, without any specific medication. Complications 
of the heart and joints demand antirheumatic treatment. 

3. PELIOSIS (PURPURA) RHEUMATICA 
(Schoenlein's Disease). 

The local manifestations of this affection consist of variously 

Hemor- ^ ^ -^ 

rhagic spots sized brie'ht- to bluish-red hemorrhae^ic spots which are unin- 

about knees <^ o r- 

and ankles, flueuced by pressure with the finger. Here and there they present 
a central papular hardness. The eruption is usually limited to 
the lower extremities, especially about the knees and ankles, but 
the upper extremities may be affected as well. The appearance 
of the eruption is preceded and accompanied by articular pain 
and swelling, occasionally soreness of the soles of the feet, and 
difliculty in walking. Fever and constitutional symptoms are 
ordinarily slight. 



In connec- 
tion with 
divers 



POLYMYOSITIS. 425 

The prognosis is usually favorable, but the disease manifests Tendency 
a tendency to recurrences, and to cardiac complications. Treat- d^iseas^e^. 
ment, symptomatic (salicylates; hemostatics, such as iron, gela- 
tin, turpentine; rest). 

MYOSITIS 

(Inflammation of the Muscles). 

The causes of myositis are very numerous. We had occasion 
to refer to scarlatinal and rheumatic myositis. It may also be 
traumatic, gonorrheal, syphilitic and tuberculous in nature, and 
is occasionally observed in connection with other infectious dis- 
ease, e.g., typhoid. Myositis is characterized by pain, swelling J^je^ti^^g 
and loss of function of the affected muscles, and in protracted 
cases by contractures. Where pain predominates and the swell- 
ing is slight, myositis may readily lead to diagnostic errors — as 
emphasized in the discussion of "muscular rheumatism" (see 
page 417). Traumatic, syphilitic and tuberculous myositides are 
prone to lead to suppuration, while simple so-called rheumatic Tendency 

.to suppura- 

myositis eventually subsides either spontaneously or under anti- tion. 
rheumatic treatment. 

POLYMYOSITIS. 

This form of general myositis is of much graver nature than 
the aforementioned varieties. It occurs either primarily, without 
any apparent cause, or secondarily as a result of parasitic infec- 

, . , . , . . . . Due to 

tion, such as trichmae, echmococci, cysticerci, etc. trichinosis, 

Gcliiiiococci 

Preceded by prodromata of a few days' duration, consisting cysticerci, 
of headache, muscular pain, anorexia and slight fever, the condi- 
tion rapidly grows worse; the temperature rises, and edema of 
the eyelids and face appears which soon spreads over the entire 
surface of the body. Beginning also with the face, the entire 
musculature of the body (least marked in the hands and feet) 

^ ^ , . ^ stiffness 

rapidly becomes stiff, board-like, and very painful, so much so interfering 

^ -^ . . .. .. with different 

that the different functions of the body (mastication, deo^lutition, functions of 

. . the body. 

respiration, etc.) are interfered with and the condition greatly 
resembles that of cerebral rigidity. 

In some cases cutaneous edema predominates (dermafomyosi- 
tis), in others a hemorrhagic condition of the skin and mucous 
membrane (polymyositis hemorrhagica). Some cases develop, 
very slowly and lead to overgrowth of the connective tissue 
(myositis fibrosa). In trichinosis the polymyositis is usually 



426 COMMUNICABLE DISEASES. 

Trichinosis preceded by gastrointestinal disturbances, and the stools and the 
wifh^gastro- muscles rcvcal trichinae spiralis. 

disturbance. In children the course of the disease is usually milder than in 

adults and, as a rule, ends in recovery. 

Treatment, symptomatic ; thorough cleansing of the alimentary 
tract; relief of pain by antispasmodics. 




Fig. 135. — Multiple Exostoses. The tumors, varying in 
size from a pea to a walnut, were especially numerous at the 
costosternal articulations, the wrist-, knee-, and ankle-joints. 

(Sheffield.) 

MYOSITIS OSSIFICANS. 

Myositis ossificans multiplex progressiva is a disease of child- 
hood, the majority of the cases on record having been observed 
in children under ten years of age. Anatomically it is charac- 



MYOSITIS OSSIFICANS. 427 

terized by progressive interstitial connective-tissue proliferation, 
with consecutive ossification. The affection begins with the 
muscles of the neck and back, then spreads to those of the the neck 
extremities, and, finally, involves the masseter and temporal 
muscles. 

The etiology of the disease is unknown. It is possibly due to 
a congenital anomaly of the connective-tissue structure. 

The onset is sudden with fever, and a soft, painful swelling Fever; 

locjilizpd 

of a section of a muscle, over which the skin appears reddened swelling, 

• gradually 

and edematous. becoming of 

bony con- 

The febrile symptoms soon abate, but the swelling in the sistence. 
muscle persists, and gradually — it sometimes takes years — 
assumes a bony consistence. Several muscles may thus become 
affected, leading to disturbances of motion, rigidity and deformi- 
ties, and ossification of a large portion of the body so that the 
patient becomes bedridden for life. The prognosis, therefore, 
is grave, and life is endangered early if the muscles of mastica- 
tion and respiration are involved. 

Treatment. — Avoidance of traumatism; the iodids internally 
and externally ; gentle massage and hot baths. 



MULTIPLE EXOSTOSES. 

Bone tumors in children may be congenital or acquired. The congenital 
latter variety has been spoken of in connection with rheumatism acquired, 
(see page 422). Congenital exostoses may escape observation 
for several years and then 'erroneously be attributed to acquired 
causes. The etiology of congenital exostoses is obscure. Some 
cases are traceable to syphilis hereditaria. Bone tumors local- 
ized in the immediate neighborhood of joints and interfering 
with motility should be extirpated. 



POLIOMYELITIS ACUTA. 

(See page 529.) 

CHOREA ACUTA. 

(See page 563.) 



CHAPTER X. 
Diseases of the Heart. 



CONGENITAL HEART DISEASE 
(Vitium Cordis). 

Delicate ^^ ^ rule, infatits born with heart disease are very delicate. 

Most of them are born asphyxiated and if resuscitated remain 

Cyanotic, cyanotic, ^ or very anemic, atelectatic, cry feebly, breathe super- 
ficially, are barely able to suckle, present a very weak pulse and 
subnormal temperature. ^ Not rarely they are born prematurely 
and with congenital defects of other parts of the body. Some 
children present a club-shaped appearance of the fingers and toes 
at an early age, some of them later. If they survive for any 
length of time their growth and development are very much 
delayed. They are helpless, begin to hold up the head or sit up 
at a much later age than the normal baby. When they start to 
rapidly^ walk they tire very rapidly. They rarely creep and when on the 
floor they are often unable to lift themselves. They are very 
susceptible to colds, and once taken sick they are very slow to 
recuperate. Bottle-fed babies frequently succumb to gastrointes- 
tinal diseases, even of comparatively simple nature. If they live 
up to school-age, and are more frequently exposed to acute con- 
tagious and infectious diseases their weakened constitution forms 
a favorable nidus for the contraction of these afifections, and is 
rarely able to withstand them. 

Even under the best of care, children with congenital heart 
lived, disease usually live but a few years. Death sometimes occurs 
suddenly, or incidentally in the course of other diseases which in 
normal children are not dangerous to life, especially respiratory 
affections. Unless the heart defect is very mild in nature, chil- 
dren with vitium cordis very rarely survive the age of puberty. 



1 From time immemorial cyanosis (morbus coeruleus or "blue-sick- 
ness") has been looked upon as a cardinal symptom of congenital heart 
disease. It is usually associated with clubbing of the fingers and toes 
(see Fig. 136). Its diagnostic importance has been greatly exaggerated, 
since it is not rarely absent in the severest forms of congenital vitium 
cordis. 

2 See "Feeble Vitality of the Newly Born." 

(428) 



CONGENITAL HEART DISEASE. 



429 



The course of congenital heart disease varies, of course, with 
the severity of the defect, but practically resembles that of SfquiJed''^ 
acquired vitium cordis, which is fully described in other parts dfsYJse. 
of this treatise. The following are the most common congenital 
heart affections : — 




Fig. 136. — Vitium Cordis. "Morbus Coeruleus." Note "club- 
shaped" fingers and cyanosis (represented by dark patches on face 
and Hps), in a child 8 years old. (Sheffield.) 

. PERSISTENCE OF THE FORAMEN OVALE. 

This condition is the result either of faulty construction of 
the foramen or its valves, or defects in other portions of the 
heart (e.g., stenosis of the pulmonary artery) which by indirect 
blood-pressure prevent complete obliteration of the foramen. 

It is the most frequent kind of congenital heart disease, but 
is not always recognizable during life. In the presence of clinical 
symptoms the diagnosis may be based upon predominance of 



Most 
common. 



430 DISEASES OF THE HEART. 

^^basic cyanosis, a systolic blowing sound at the base of the heart or over 
murmur, the third or fourth costal cartilage. 

PERSISTENCE OF THE DUCTUS ARTERIOSUS BOTALLI. 

Complete obliteration of this duct is supposed to occur by the 

end of the third month. This may be retarded or may entirely 

fail — usually in cases where the left ventricle is not properly 

filled with each heart-cycle (e.g., in atelectasis, fetal pneumonia, 

stenosis of the pulmonary artery) — in which event the blood 

from the pulmonary artery continues to flow through the ductus 

arteriosus to the insufficiently filled aorta. As a result of this 

Hypertrophy anomaly there develops sooner or later hypertrophy of the right 

ventricle, ygntricle, usually with dilatation of the pulmonary artery. 

The symptomatology is very variable. 

In cases of only partial patency the symptoms may be so 

slight as to escape observation. Complete patency of the duct 

very gradually gives rise to the following group of symptoms : 

Thrill; Disposition to respiratory affections, cyanosis, or waxy pallor; 

murmur^ over dyspnea, cool extremities, palpitation, a thrill over the anterior 

precor mm. ^.j^^g^ ^^11, increased cardiac dullness to the right, accentuation 

of the second pulmonic sound, loud systolic murmur over the 

precordium, often epistaxis or hemorrhage from other mucous 

membranes ; finally, sometimes not until after several years of 

existence, marked symptoms of failure of compensation with 

rapid fatal termination. 

DEFECTS IN THE SEPTUM VENTRICULORUM 
(Communication of the Ventricles). 

It is a very common condition, most frequently the result of 

fetal myocardial diseased processes, and not rarely coexisting 

with congenital stenosis of the pulmonary artery. The defect is 

situated either in the anterior or posterior portion of the septum. 

Very rarely the whole wall between the ventricles and auricles is 

absent so that all four heart cavities communicate. 

M rked Accentuatiou of the second pulmonic sound ; overfilling of the 

.^cyanos^s veins ; marked cyanosis developing soon after birth or, more 

birth, gradually, some time after, and hypertrophy and dilatation of the 

right ventricle — all point to a defect of the ventricular septum. 

A positive diagnosis, however, is almost impossible during life 

of the patient. 

The prognosis is very bad. 



ir. 



CONGENITAL HEART DISEASE. 431 

CONGENITAL STENOSIS OF THE PULMONARY ARTERY. 

The stenosis may involve the orifice alone, the entire trunk, 
or the branches of the pulmonary artery. Accordingly the symp- 
tomatology varies with extent and location of the lesion. As a 
rule, there is marked cyanosis from birth. Some children are Bom with 

... . cyanosis. 

born asphyxiated, and if resuscitated continue to suffer from 
attacks of suftocation and convulsions, to which they usually 
succumb within the first few days of life. Stronger children may 
survive these attacks, gain some strength, lose part of the cyanosis 
and live several years. 

Physical examination reveals arching of the anterior left 
chest wall ; enlargement of the cardiac area, chieflv to the rig^ht ; ^^^}^,. 

' ^ ^ & ' systolic 

diffuse systolic murmur, heard loudest over the left second and murmui 
third costal cartilages, and often a purring thrill on palpation. 

CONGENITAL STENOSIS OF THE TRICUSPID VALVE. 

It is usually the result of an anomalous or excessive develop- 
ment of muscle substance instead of the valve, or of fetal endo- 
carditis, and is often associated with other congenital heart 
defects. 

The symptomatology resembles that of stenosis of the pul- 
monary artery, except that the murmur is heard loudest over the Scuspid 
fourth and fifth costal cartilages, and hypertrophy of the right 
side is either absent or very slight. 

The prognosis is unfavorable. 

CONGENITAL STENOSIS OF THE OSTIUM ATRIO- 

VENTRICULARE SINISTRUM 

(Stenosis of the Aorta). 

The stenosis may be situated at the point of origin of the 

aorta ; at any place throughout the entire aortic system ; or at the 

ductus Botalli. 

As a result of either one of the aforementioned conditions 
there is hypertrophy of the left heart. A^arying with the seat of 
the atresia, the blood-vessels given off above the lesion may be 
abnormally filled with blood, while those emerging below the 
lesion suffer from a deficiency of it. Between the two groups of 
vessels a collateral circulation is usually established, which may 
frequently be recognized by numerous, visible, actively pulsating, 
subcutaneous blood-vessels over the thorax. A svstolic murmur °/ biood- 

•^ vGSSGlS. 

is often heard over the dilated arteries. The heart is usuallv 



Murmur 
over 
tricus; 
valve. 



Hypertrophy 
of left 
heart. 



Pulsation 



432 DISEASES OF THE HEART. 

inurmur^ free from any auscultatory signs, unless the orifice of the aorta 
be involved, when a loud systolic murmur may be heard at mid- 
sternum. 

The patient may live for several years — until compensation 
ruptures. Death sometimes ensues very suddenly from rupture 
of a group of vessels above the stenosis. 

Treatment. — The treatment of congenital heart diseases is 




Fig. 137. — Dextrocardia in a Girl 6 Years Old (skiagram; back 
view). {Sheffield.) 

essentially the same as that of acquired, and is fully outlined 
°™re^st on page 443. Complete rest in the strictest sense of the word 
will help to prolong life — possibly to an advanced age. 

DEXTROCARDIA. 

Among the few congenital malpositions of the heart (meso- 
cardia — the heart occupies a central position of the chest-wall ; 
ectopia cordis — the heart may be situated either between a fissure 
in the sternum immediately beneath the skin, in the neck, or in 
the abdomen below the diaphragm) dextrocardia, or transposi- 
tion of the heart to the right side, is of special interest inasmuch 
as it very rarely interferes with the life or welfare of the patient. 



ACQUIRED HEART DISEASE. 



433 



Dextrocardia is often associated with a general transposition of often trans- 
the viscera. The aorta and its branches usually remain in their vfg^cera? °^ 
normal situation. Dextrocardia should not be confounded with 
displacement of the heart by large effusions or growths in the 
thoracic cavity. 



ACQUIRED HEART DISEASE. 
MYOCARDITIS. 

Inflammation of the muscular tissue of the heart is occa- 
sionally congenital, a sequel of infection during fetal life, but 
most frequently acquired, occurring either secondarily to acute 
infectious diseases, or as a result of extension of an inflamma- 
tion from the inner or outer lining of the heart. 

The inflammation may be diffuse or circumscribed, and as in 
adults either plastic or interstitial, or degenerative or parencJiy- 
matous. 

The interstitial variety of myocarditis usually leads to sup- 
puration and abscess formation of the musculature. In parenchy- 
matous myocarditis the transverse striae of the fibrillse appear 
lost, the muscle consisting chiefly of fatty and granular matter. 

The course of the disease varies greatly with the underlying 
cause and the rapidity of the inflammatory process. 

In the majority of instances interstitial myocarditis is com- 
plicated by endocarditis and pericarditis, and in consequence of 
preponderance of the signs of the latter affections it is very 
seldom possible early to diagnose the existence of the myocardi- 
tis. In cases where the inflammation is circumscribed, myocarditis 
may be surmised by the sudden precordial pain, dyspnea, high 
fever, restlessness and deHrium. The apex-beat and pulse are 
weak, arhythmic and rapid. Death is the usual termination; not 
rarely occurring suddenly (sometimes from rupture of the abscess 
in the heart cavities) with symptoms of sudden collapse. 

Parenchymatous myocarditis ordinarily runs a slow and latent 
course. Occasionally, however, the degenerative process develops 
quite rapidly. Extreme pallor, breathlessness, and weak and 
galloping pulse point to the involvement of the myocardium, but 
in the early stages the diagnosis can rarely be made with any 
degree of certainty. As the disease advances and symptoms of 
cardiac dilatation and passive pulmonary congestion set in. the 
diagnosis is fairly certain. 

The treatment is the same as in endocarditis {q.v.). 

28 



Usually 
acquired. 



Interstitial. 



Sudden 

precordi£ 

pain. 



Arhythmia. 



Parenchyma- 
tous. 



Slow course. 



Galloping 
pulse. 



434 DISEASES OF THE HEART. 

PERICARDITIS. 

Like pleuritis, inflammation of the pericardium may occur in 
dry form or with an effusion. The exudation may be sero- 
fibrinous, hemorrhagic, or purulent. Dry as well as exudative 
" aSieSons^ pericarditis usually gives rise to inflammatory adhesions between 
the pericardium and heart, and occasionally to the anterior and 
posterior chest-walls and vertebral column. Chronic pericarditis 
is productive of grave disturbances of the circulation, cardiac 
hypertrophy and dilatation. 

The gravity of this afifection should, therefore, not be under- 
estimated. The prognosis is serious, especially in the secondary 
variety occurring in connection with tuberculosis, septic pro- 
cesses, pleuropneumonia, caries of ribs or vertebrae, severe 
exanthematous diseases (e.g., scarlatina), purpura hemorrhagica, 
chronic nephritis, etc. It is less dangerous in primary, usually 
rheumatic form, particularly if the patient is over three years of 
age, or when caused by syphilis and is detected and treated early. 

Bearing in mind the etiologic factors just enumerated, we can 
readily appreciate that pericarditis in children must be quite 
common. Indeed, there is ample reason for the belief that in 
children over three years of age pericarditis is more frequent 
than endocarditis — with which affection, by the way, it is not 
rarely associated. 

The onset of primary pericarditis is usually very sudden, but 
pg^gj.. sometimes, like in the secondary variety, it may be insidious, 
oppressfon^ Ordinarily it is ushered in with high temperature, vomiting, 
cough, cardiac oppression, dyspnea, and accelerated pulse. Cough is an 
early symptom and, in the presence of an effusion, quite pro- 
nounced. This symptom is probably due to cardiac pressure 
against the lungs. The pulse, which in dry pericarditis is strong, 
in marked exudative pericarditis it is often very feeble, barely 
perceptible, and irregular. Pain is frequently intense, especially 
if associated with polyarthritis. The patient is restless, sleepless ; 
his expression of the face is anxious, denoting great suffering. 
Of course, the symptomatology is greatly modified by that of the 
underlying affection, if existing. 

The physical signs vary with the stage of the disease. Before 

the development of the effusion auscultation elicits superficial, 

To-and-fro exocardial, to-and-fro friction and creaking sounds, limited over 

friction. ' ' ... 

the cardiac region, often changeable with position of the patient 



Wide 
apical 
dullness. 



hypertrophy. 



ACQUIRED HEART DISEASE. 435 

and audible independently of the heart sounds. Endocardial 
murmurs may coexist. When serous effusion occurs, the friction 
sound is found diminished or absent, the heart impulse very feeble impuiL. 
(whereas the pulse may be felt quite strong), the area of heart- 
dullness greatly increased and wider at the apex than at the base, 
and when the effusion is large we notice also diminution of the 
respiratory movements of the left side. With absorption of the 
fluid in the pericardium there is gradual return of the symptoms 
of the first stage and in favorable cases restitutio ad integrum, 
or, quite frequently, supervention of pericardial adhesions with 
consecutive systolic retraction of the chest-wall over the 
entire precordium. The percussion symptoms are not absolutely 
reliable, since increase of the area of cardiac dullness is also 
observed in dilatation or hypertrophy. There are, however, 
several other distinctive features which render the differentiation tion from" 
of pericardial effusion from enlarged heart possible. Thus, in 
dilatation or hypertrophy of the left ventricle the apex-beat is 
felt at the extreme left limit of the dullness and at its lowest level, 
while in effusion the apex-beat or rather the heart-impulse is at a 
spot inside and above the boundaries of the cardiac dullness, 
somewhere between the fourth or third interspace. In pericardi- 
tis the dullness develops much more acutely than in an enlarged 
heart, which latter occurs usually secondarily to more or less 
chronic valvular disease. However, we should bear in mind that 
pericarditis, acute or chronic endocarditis, and hypertrophy and 
dilatation may coexist and give rise to a symptom-complex beyond 
the possibility of individualization. For the differentiation 
between pericarditis and endocarditis the reader is referred to the 
discussion of the latter affection (see page 439). 

The nature of the effusion can readily be ascertained by 
exploratory puncture, but even without it we may surmise the 
presence of pus if the pericarditis develops secondarily to septic 
processes; blood, after severe trauma, and scrum, in primary, 
usually rheumatic, pericarditis. 

The determination of the character of the effusion is impor- 
tant especially as regards the further course and treatment of the 
disease. 

Rheumatic pericarditis, if free from complications, usually 
lasts for from two to three weeks or longer. After about 
ten days there is gradual evanescence of the symptoms. Not 
infrequently, however, the "apparent" recovery is only tempo- 



Nature of 

effusion. 



436 



DISEASES OF THE HEART. 



Rheumatic. 



Purulent. 



Tuberculous. 



Rest; 

icebag; 

salicylates. 



Aspiration. 



lodids. 



rary, inasmuch as there may be a return of the effusion, or 
development of valvular deposits, which sooner or later give rise 
to marked valvular disease. These manifestations are partic- 
ularly prone to occur in pericarditis with polyarthritis. Peri- 
carditis, like endocarditis, not rarely precedes the joint symptoms, 
may run a latent course and disappear again without being 
detected — possibly not until repeated recurrences and appearance 
of complications. More rarely, pericarditis ends in death either 
rapidly as result of cardiac muscular insufficiency and pulmonary 
edema, or slowly from early complications, such as pleurisy, 
pneumonia, severe adhesions, endocarditis, etc. 

Purulent pericarditis pursues a much more violent course. 
Extreme fatigue, severe attacks of syncope and pyemic fever 
predominate, while the local symptoms are comparatively insig- 
nificant. Even the exudation is often slight. When it occurs in 
conjunction with tuberculosis, it is very malignant in character. 
It is then manifested by enormous hypertrophy of the peri- 
cardium, extensive adhesions, large quantity of pus between the 
heart and pericardium, and numerous tubercles in the latter. It 
is invariably fatal. The same holds true for pyemic pericarditis, 
in which streptococci, pneumococci, staphylococci and less fre- 
quently gonococci act as the principal exciting cause. 

A disease presenting so many phases as pericarditis can at best 
be treated only symptomatically. Absolute rest in bed, an icebag, 
or a flaxseed-meal poultice, to the precordium, and sodium salicy- 
late (1 grain for every year of the child's age every two hours) 
and codein (%oo of a grain every six hours) internally will often 
do well in rheumatic cases. In large pericardial serous effusions 
with threatening syncope we may try free diuresis, with or with- 
out aspiration (in the fifth intercostal space a Httle to the left of 
the border of the sternum). The latter procedure frequently 
proves useful in small non-tuberculous purulent effusions, while 
in large purulent effusions incision and drainage are preferable 
to aspiration. 

In quite a number of cases sodium iodid seems to exert a 
specific effect, and bearing in mind also the possibility of under- 
lying latent syphilis we should always administer this remedy 
irrespective of the variety of the pericarditis and the mode of 
treatment simultaneously employed. Digitalis or strophanthus 
may be given to strengthen the heart. 



Rheumatic. 



ACQUIRED HEART DISEASE. 43^ 



ENDOCARDITIS ACUTA. 

The etiologic factors of acute endocarditis are essentially the 
same as in periparditis (q.v.), except that the former is more 
frequently associated with rheumatic affections, such as arthritis, 
chorea, tonsillitis, erythema nodosum, etc., and not rarely com- 
plicates pericarditis. Invasion of the endocardium by the strep- 
tococcus, staphylococcus, pneumococcus, the bacillus pyocyaneus, coccic, etc. 
tubercle bacillus and gonococcus usually occurs through the cir- 
culating blood, giving rise to a pathologic condition very similar 
to that observed in adults. 

The inflammation which is usually limited to the left side of 

Pathologic 

the heart first attacks the vascular layer of the endocardium findings, 
between the muscular and fibrous coats, resulting in an exudation 
of lymph and serum principally beneath and on the free surface 
of the membrane covering the valves and chordae tendinese. As 
the disease progresses large or small papillary nodules, vegeta- 
tions, are formed on the endocardium — endocarditis verrucosa, 
or ulcerations occur as a result of destruction of the superficially 
necrosed tissue — endocarditis ulcerosa. The latter condition is 
usually found in the malignant, usually septic, form of endocar- 
ditis. During the course of endocarditis many organs of the 
body, e.g., the kidneys, spleen, brain, etc., may become implicated 
through emboli composed of masses of fibrin or necrosed tissue 
which become detached by the circulating blood principally from 
the irregular valvular deposits. In septic cases these emboli give 
rise to abscesses. It is well to remember, however, that moder- 
ately severe cases of endocarditis may go on to complete recovery, 
and leave no trace of the original inflammation on the endo- 
cardium; furthermore, that slight valvular vegetations are not 
infrequently found post mortem without any apparent clinical 
signs of heart disease during life. 

This latter observation can readily be explained by the fact 
that mild endocarditis is not rarely masked by the course of 
another disease, and unless presenting marked disturbance of the 
circulation is very apt to be overlooked. More often, of course, 
endocarditis sets in with severe unmistakable symptoms. The cmiis, fever, 

_ ^ precordial 

patient vomits, suffers from chills, more or less hiHi fever (102° distress and 

^ ^ _ o \ cough. 

to 105°), precordial distress, short cough, dyspnea, and acceler- 
ated and sometimes irregular pulse. These symptoms, however, 
are not sufficiently characteristic of endocarditis and may still 



438 



DISEASES OF THE HEART. 



leave the nature of the disease obscure until the subsequent 
Usually appearance of local signs, especially of a systolic heart murmur, 
muniiur. audible chiefly at the apex (the mitral valve being most fre- 
quently involved) or also over the whole cardiac region. As will 
be seen later (see "Endocarditis Chronica," page 439) murmurs 
may subsequently develop at the various orifices of the heart, 
and at a later stage of the disease additional physical signs (dila- 
tation or hypertrophy) may be obtained by percussion. 

Occasionally (in children less frequently than in adults) acute 





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Fig. 138. — Fever Curve of Malignant Endocarditis in a Child 
3 Years Old. (Sheffield.) 



Malignant 
form. 



Septic 
symptoms. 



endocarditis pursues a very septic and often violent course — 
endocarditis maligna (ulcerosa). It may be preceded by pneu- 
monia, exanthematous diseases, septic processes in some other 
parts of the body, etc., or occur without any apparent cause and 
exhibit a symptom-complex resembling either a low typhoid 
state or cardiac insufficiency with acute dilatation (cyanosis), and 
loud murmurs at the various orifices. The duration of malignant 
endocarditis varies. Ordinarily it runs a protracted course with 
irregular temperature, chills, rigors and sweats. Sooner or later 
emboli develop in different organs of the body and the capillaries 
of the skin the superadded symptoms varying, of course, with 
the organ affected. If the brain is involved, we find palsies with 
disorder of consciousness ; if the spleen, enlargement of this 



CONGENITAL HEART DISEASE. 439 

organ and tenderness; if the kidneys, albuminuria, hematuria and [Jo^gP^*^^* 
anasarca; if the skin, petechise and a pustular eruption. It is 
not rarely complicated also by purulent pericarditis. When 
malignant endocarditis runs so very violent a course it, as a rule, 
terminates fatally within a few days. On the other hand, simple, 
benign endocarditis in children is usually not dangerous to life. 
If free from complications the symptoms begin to subside after 
about a week or ten days, eventually leading to recovery in about 
four weeks. In quite a number of cases, however, it is followed 
by permanent valvular disease, with or without cardiac hyper- 
trophy (see "Endocarditis Chronica"). Death is usually due to 
cardiac paralysis. 

Benign endocarditis may be mistaken for dry pericarditis, 
especially if the former is associated with articular rheumatism. 
The following table contrasts the most important distinguishing 
features. Both diseases, however, may coexist. 

Differential 

Simple Endocarditis. Dry Pericarditis. diagnosis 

from 
Blowing or musical sound. "To and fro" friction or creaking pericarditis, 

sound. mllSt 

Sound is associated with systole or Not necessarily. May be heard at miliary' 

diastole. any period of cycle. tuberculosis 

Sound is distant. Near to the ear. ^°^^ 

Sound is uninfluenced by pressure Increased. 

with the stethoscope. 

Sound is conducted upward, to the Not so. 

axilla, and to the back. 

Sound usually loudest at apex. Anywhere over precordium. 

The diagnosis of ulcerative endocarditis is very difficult, 
especially in the incipient stage, before the appearance of a heart 
murmur. Whenever several orifices are the seat of the murmur, 
paroxysms of cyanosis and dyspnea and irregular temperature 
predominate, and cardiac dullness is increased, the diagnosis of 
malignant endocarditis is justified. The elimination of typhoid, 
irregular malarial fever, miliary tuberculosis, and pyemia, the 
four affections with which malignant endocarditis is most apt 
to be confounded, will greatly facilitate the diagnosis. 

The treatment of endocarditis is essentially the same as in 
pericarditis — purely symptomatic. (See "Pericarditis," page 436.) 

ENDOCARDITIS CHRONICA 
(Valvular Heart Disease). 

Chronic endocarditis is most frequently a sequel of acute 
inflammation of the endocardium, especially of the valves, and 
pathologically consists of proliferation and thickening of the 



pyemi 



440 



DISEASES OF THE HEART. 



Limited to 
left heart. 



Hyper- 
trophy. 



Dilatation. 



Anemia. 



Pulmonary 
edema. 



Complica- 
tions. 



valvular connective tissue with a great tendency to contraction 
and adhesions, and very rarely to calcification. The chronic 
inflammatory process is usually limited to the left side of the 
heart except in cases developing during fetal life, when the 
reverse is the case. 

Coincident with the inflammatory process in the endocardium, 
the cardiac musculature undergoes gradual enlargement. This 
hypertrophy, unless assuming exceptionally large dimensions 
{e.g., cor hovinum), is strictly speaking not a disease per se, but, 
on the contrary, an efl:ort on the part of nature to overcome or 
undo the evil effects of the disease. As the disease advances and 
the heart muscles lose their power, get exhausted, the hyper- 
trophy is replaced by dilatation, indicating that compensation has 
''ruptured," and that disease is beyond control. 

Until failure of compensation has occurred children may for 
years remain apparently free from any marked disturbances of 
health, except, perhaps, rapid fatigue, palpitation of the heart 
on exertion, progressive anemia and malnutrition notwithstanding 
good appetite and digestion. Indeed, it is often chiefly for dis- 
turbance of the latter that the patients are brought to the physi- 
cian. Shortness of breath, which increases on exertion, usually 
forms an early manifestation of failing compensation. It is 
the result of stasis in the pulmonary circulation with con- 
secutive impairment of aeration. This sooner or later leads to 
passive congestion of the pulmonary alveoli, giving rise to bron- 
chitis, with an irritable cough, and, as the heart-failure increases, 
to paroxysmal attacks of dyspnea especially at night (''cardiac 
asthma"), pulmonary edema, cyanosis, and occasionally to 
hemorrhagic infarcts in the lung with consecutive hsemoptoe. 

Simultaneously with the aforementioned manifestations, 
pathologic changes go on also in other internal organs — the liver, 
spleen, and kidneys. The liver and spleen are enlarged, and by 
pressure upon neighboring thoracic organs increase the dyspnea. 
As a sequel of the passive congestion of the liver and stasis in 
the blood-vessels of the stomach and intestines, numerous gastro- 
intestinal disturbances — e.g., anorexia, vomiting, constipation — 
develop, which add misery to the patient's painful existence. 

The changes in the kidneys are manifested by diminution in 
the quantity of urine, often albuminuria (slight), hyaline and 
cylindrical casts, and occasionally white and red blood-corpuscles 
— signs of passive congestion. 



ACQUIRED HEART DISEASE. 441 

\Mth increasing venous stasis there is coincident transudation 
of the fluid of the blood from the capillaries into the meshes of 
the tissues, leading to edema. At first the dropsy is limited ^°P^y- 
usually to the ankles and eyelids, but as the disturbance of circula- 
tion advances it grows worse and involves the entire integument 
and the internal cavities, especially the abdominal and pleural 
cavities. Notwithstanding the extreme gravity of the condition, 
the end is not always as near as would be expected. The inherent Remissions, 
power of the infantile heart is still capable of temporary repara- 
tion. The arhythmia, dyspnea, and dropsy may disappear ; the 
appetite and nutrition may improve ; the tottering patient may 
again be up and around ; in fact, may appear at his best. Exacer- 
bations and improvements of the disease may come on several 
times. The improvement is but short-lived. \'ery soon the 
symptoms return, and, as a rule, with greater severity. Finally, 
after a more or less prolonged period of illness the patient 
succumbs to heart-failure. Occasionally death occurs suddenly failure, 
after severe exertion. Quite a number of children are carried 
away by intercurrent infectious diseases, pericarditis or recurrent 
endocarditis. The physician should therefore always be very 
guarded in the prognosis. The relative gravity of valvular 
lesions is as follows : Tricuspid regurgitation ; mitral regurgita- 
tion; mitral stenosis; aortic regurgitation; pulmonic stenosis; 
aortic stenosis. 

Differential Diagnosis. i — As the physical signs of valvular ^j,^a?ir%f 
heart disease in children differ but little from those in adults, we lesions. 
will review only the most essential differential points of diagnosis. 

MITRAL REGURGITATION. 

Insufficiency of the mitral valve is characterized by a systolic 
blowing murmur which is loudest at the apex and transmitted 
to the axilla and near the lower angle of left scapula. Accent- 
uation of the second pulmonic sound. Hypertrophy of the left 
ventricle, and later left auricle, and sequential hypertrophy of the 
right ventricle. The pulse may be normal or accelerated, and 
with disturbed compensation — which may not occur for many 
years — irregular and unequal. 

MITRAL OBSTRUCTION. 

It is frequently associated with insufliciency. The murmur is Presystolic 

11 1- 1 1- 1- 1 1 1 1 °^ diastolic 

usuallv presvstolic or also diastolic, best heard at the apex ; mav murmur at 

apex. 
1 See Fig. 16. 



Systolic. 
murmur 
at apex. 



442 



DISEASES OF THE HEART. 



Diastolic 
murmur at 
right base. 



be conveyed to the fourth interspace, but never to the angle of 
the scapula. The pulmonic second sound is accentuated and 
sometimes double. It frequently leads to hypertrophy of the left 
auricle and right ventricle. 

AORTIC REGURGITATION. 

Aortic insufficiency is rare in children. It is accompanied by 
hypertrophy of the left ventricle, and often pulsation of the 
arteries of the neck. The murmur is diastolic, loudest at the 
insertion of the right second costal cartilage and over the upper 
portion of the sternum. At first the murmur is quite noisy, but 
with ensuing disturbance of compensation it loses its intensity. 
It is usually combined with aortic stenosis, becoming the gravest 
form of valvular disease of childhood. It sometimes causes 
sudden death, and but few children survive the age of puberty. 
Aortic regurgitation may often be recognized by its peculiarly 
collapsing pulse — the water-hammer or Corrigan's pulse. 



Systolic 

murmur 

at right 

base. 



AORTIC OBSTRUCTION. 

This affection is usually observed in older children in connec- 
tion with aortic insufficiency. The murmur is harsh, systolic, 
heard loudest over the aortic orifice, transmitted to the right, and 
sometimes over whole length of sternum, and the arteries of the 
neck. Hypertrophy of the left ventricle. 



TRICUSPID REGURGITATION. 

Except as a congenital defect it most frequently occurs 
secondarily to affections of the left heart. Auscultation reveals 
murmur a systolic, blowing murmur heard loudest over the lower part of 



xiphoid. 



the sternum (xiphoid) and at the juncture of the fourth costal 
cartilage. Second sound is weak. Jugular pulsation. Hyper- 
trophy and dilatation of the right heart. In severe cases cyanosis, 
and pulsation of the liver. 

TRICUSPID OBSTRUCTION. 

This condition is extremely rare ; hence, calls for no detailed 
discussion. No particular change in size of the heart is known. 
(See "Congenital Heart Disease.") 



PULMONIC REGURGITATION. 

Insufficiency of the pulmonic valve is chiefly congenital rarely 
acquired. The murmur is diastolic and limited to the site of the 



ACQUIRED HEART DISEASE. 448 

valve — at the junction of the left second costal cartilage and Diastolic 

the sternum. Unlike that of aortic insufficiency it is not trans- Sft^^as'e.^*^ 

mitted to the arteries of the neck. Hypertrophy of the right 
heart. 

PULMONIC OBSTRUCTION. 

Principally a congenital malady. The murmur is basic, sys- 
tolic, heard loudest at the left second costosternal junction. It is murmur at 
associated with hypertrophy of the right ventricle, and some- 
times cyanosis. (See "Congenital Heart Disease." ) 

Functional or inorganic murmurs — those arising during the 
course of acute febrile diseases or in association with anemic 
conditions — may be mistaken for organic murmurs of valvular 
heart disease. The chief points of distinction between them are 
as follows : Functional murmurs are inconstant, heard prin- Differentia. 

11 1 1 -1 1 -1 r 1 ^^°^ from 

cipallv at the base with svstole, not transmitted awav from the organic 

1 ' 1 11 1- ^-11- • ' murmurs. 

heart, and usually disappear with detervescence, or improvement 
of the anemia. Functional murmurs are very rare in children 
up to seven years of age. 

The management of chronic valvular heart disease in chil- 
dren is the same as in adults. It differs with the stages of the 
disease — when compensation is intact, and when it "ruptures." 

STAGE OF COMPENSATION. 

The well-being and longevity of the patient stand in direct 
ratio to the capacity of the heart to compensate its insufficiency 
by secondary hypertrophy of the musculature of one or more of 
its chambers. Hence, the aim in the treatment of chronic val- ,.,=„, ^„,„ ^ 

Maintenance 

vular heart disease should be directed chiefly to the maintenance peng^Toj-y 
of compensatory hypertrophy. Bearing in mind the facts that iiypertrophy. 
with increasing circulatory disturbance there is on the part of 
the heart a spontaneous muscular development to overcome its 
difficulties as long as its supply of nourishment is sufficient, and 
its hypertrophic process is not interfered with by unequal 
demands upon its reserve force — as it is apt to occur, e.g., in 
overexertion, intercurrent diseases and the like — we can readily 
formulate a plan of treatment which will, at least for a time, 
amply meet with the aforementioned indication. Parents should 
be given to understand that the treatment of compensating heart 
disease is principally prophylactic and hygienic, and that its 
success is commensurate with the degree of co-operation on the 



444 DISEASES OF THE HEART. 

part of the patient as well as those guiding his destiny when the 
heart is at its best. 
Care Convalescence from acute or recurrent heart disease calls for 

convaies- Very careful attention. Too early attempts at walking or standing 
are apt to prove disastrous, not rarely leading to sudden dilata- 
tion of the heart, perhaps, with fatal issue. Beginning with 
gradual raising of the head and shoulders, and watching its effect 
upon the patient's heart-action — strength and rhythm — we may 
gradually allow greater liberties, provided slight exertion is 
unattended by detrimental influences. In severe cases of valvular 
heart disease it is usually not safe to permit the patient to be out 
and around in less than three months. A sojourn in a quiet inland 
resort is very helpful to recovery. 

A heart with crippled valves demands an adequate supply of 

nutrition, healthy blood in the coronary arteries. This is best secured by 
suitable nutrition and a rational mode of living. The diet must 
be appropriate to the age of the patient, at all ages milk forming 
the principal food-ingredient. A vegetable diet with small quan- 
tities of light meats is suitable in most cases. Liquors and 

Non-alco- , ^ . . .... 

hoiic tonics, stimulants of all kinds should be avoided, administering instead 
nutrient tonics such as malt and cod-liver oil, with or without 
small quantities of iron and arsenic, etc. 

Especial attention should be paid to the action of the bowels, 
Outdoor kidneys, and skin. Daily cool sponging followed by gentle 
air. massage is very invigorating. Warm clothing is essential, but 
unnecessary coddling of the patient should be interdicted. 
Weather permitting, the child should be kept outdoors from nine 
in the morning until about five o'clock (later in the summer) in 
the evening, allowing him to participate in all such amusements 
as will not call for undue exertion. Racing, jumping, football, 
Avoidance ^^^ bascball playing and swimming should be forbidden. Light 
and^mentai athletic cxercisc is uscful if it gives rise to no undue fatigue, or 
overexertion, disturbance of Compensation. Passive exercise, in the form of 
massage, is highly to be recommended. The question of how 
much brainwork a patient with poorly compensating heart disease 
is to be permitted to do cannot be decided offhand to apply to all 
cases. Its effect upon the general health of the patient must be 
watched, and changes in the curriculum promptly made if head- 
ache, insomnia, anemia, debility, excessive nervous irritability, 
and the like make their appearance. 

It is of very vital importance to obviate intercurrent diseases. 



ACQUIRED HEART DISEASE. 445 

especially infectious diseases, such as scarlatina, articular rheu- Prevention 

^ ^ -^ . . of comniuni- 

matism, etc., which are apt to reinfect the endocardium, and ^f^J^g^g 
aggravate the patient's condition. If such diseases prevail it is 
imperative, whenever practicable, to isolate the child, or remove 
him to a place where he will be least exposed to infection. For 
fear of contracting contagious diseases, patients in good financial 
circumstances should be kept from visiting public or private 
schools and preferably be instructed at home. 

Particular attention should be paid to incipient symptoms of 
tonsillitis, "growing pains," etc. — forerunners of rheumatism. In 
these conditions the salicylates should be resorted to early to 
prevent graver rheumatic manifestations. 

AA'ith every appearance of indisposition the patient should be 
put to bed, and kept there until every vestige of the malady has 
abated. 

In intercurrent febrile diseases the heart demands very careful 
watching, and in the presence of any disturbance immediate 
treatment. 

STAGE OF FAILING COMPENSATION. 

A^arying with the inherent strength of the patient, the severity 
of the lesion and the precautionary measures employed, compen- 
sation may be maintained for a shorter or longer time — weeks, 
months or years. However, it is only a question of time when 
compensation ruptures. As previously mentioned, the break- 
down may be only temporary — readily yielding to a few weeks 
of rest, careful feeding, possibly requiring also a few doses of 
digitalis — and recur on several occasions. But sooner or later the 
heart muscle 2:ives way — the pulse becomes feeble and irre2:ular, heart- 

^ ■' ^ & ^ failure. 

the breathing deep and difficult, the urine diminished in quantity 
and the general condition of the patient greatly impaired. Here 
rest in bed is indispensable, but this alone is not sufficient to restore 
compensation. We have to resort to cardiac stimulants to 
strengthen the heart muscle and to regulate its beat, and to vaso- 
dilators, with each ventricular contraction, to allow the blood to 
flow in the arteries without resistance. Various drugs are being 
recommended for this purpose, but none meet the indications j^. .^^j.^ 
with the same degree of certainty as digitalis, and the iodids. f^^^^^g^® 
In incipient failure of compensation we usually begin, for every 
two years of the child's age, with half a grain of the sodium iodid 
and a quarter of a dram of the infusion of digitalis, to be 



446 



DISEASES OF THE HEART. 



repeated every six hours, and as the disease advances increase the 
doses proportionately up to one grain of the iodid and one dram 
of the digitahs. The cumulative action of the digitalis should be 
borne in mind, and its administration discontinued if untoward 
strophan- symptoms arise. In this event, or where digitalis is not well 
caffeine! tolerated by the stomach, we may substitute strophanthus, caffeine 
sodium benzoate or spartein sulphate instead. The latter two 
remedies have the advantage that they may be safely given 
hypodermatically if irritability of the stomach precludes their 
administration by mouth. 

In the early attacks of failure of compensation the effects 
obtained from the simple mode of treatment just outlined are 
often entirely beyond expectation. Sometimes within but a very 
few days the urine greatly increases in quantity, the edema dis- 
appears, the dyspnea ceases, the distressing cough abates — in 
short restoration of compensation is apparently complete. In the 
later stages of compensatory failure, however, the treatment by 
means of rest, good food, the iodids and digitalis fails to assert 
its magic influence. We have to resort to symptomatic medica- 
symptomatic tiou, especially with the view of relieving suffering. In this 

treatment. , . , , , , . , . 

respect the treatment is the same as that employed m adults, 
morphine with atropine being the most potent remedy at our 
command. 



R Strychninae sulph gf- % 

Natrii iodidi gr. xvj 

Inf. digitalis fol Sj 

Syr. althese q. s. ad Si j 



0.008 

1 
30 
60 



M. Sig. : 3j t. i. d. for a child 4 years old. (Alterative heart-tonic.) 

B Syr. ferri iodidi 3iij | 12 

Syr. aurantii q. s. ad 5ij | 60 

M. Sig.: 3j every four hours for a child 4 years old. (Between 
"heart attacks.") 

B Liq. ferri et ammonii acetatis, 

Inf. digitalis fol aa Sj | 30 

M. Sig. : 3j every four hours for a child 4 years old. (When dropsy 
is present.) 

^ Tr. digitalis, 

Tr. strophanthi aa 3ij | 8 

M. Sig. : Gtt. v every four hours for a child 4 years old. (In marked 
heart-dilatation with irregularity.) 

I^ Strychninae sulph g^- H. O-^O^ 

Caffeinae natrii benzoatis gr. xij 0.8 

Aq. destil 3ij 8 

M. Sig. : Gtt. X, hypodermatically, p. r. n. for a child 4 years old. 
(Quick stimulant.) 



CHAPTER XI. 
Diseases of the Kidneys, Bladder, etc. 



NEPHRITIS ACUTA. 

Acute nephritis is most frequently met in association with common in 



acute infectious and contagious diseases, especially scarlatina, 
diphtheria, and pneumonia. Less frequently it occurs as a 
result of exposure to wet and cold; of structural alterations of 
the skin, e.g., extensive burns ; of ingestion of certain irritants to 
the kidneys, e.g., cantharides, potassium chlorate, aspidium, etc., 
and, finally, not rarely it is observed in infants suffering from 
gastroenteric affections. The aforementioned causes usually 
operate upon both kidneys, so that both kidneys are equally 
affected. The lesion may, however, remain limited to one kidney 
where the disease is caused by direct, unilateral trauma. The 
seat of the kidney lesions varies somewhat with the cause. For 
example, the glomeruli {glomerular nephritis) are most severely 
involved in scarlatina, while in diphtheria we most commonly 
find degenerative changes in the renal tubules {degenerative or 
parenchymatous nephritis). But no particular form of acute 
nephritis is peculiar to a given cause. In severe cases the kidneys 
are greatly increased in volume and weight. The surface is 
smooth and the capsule readily removable. The renal cortex is 
either uniformly reddened or pale and mottled with red. The 
tubuli uriniferi are partly or completely obstructed by large 
granular epithelial cells, blood-corpuscles and fibrin. In the 
early stage of the disease the interstitial tissue shows no altera- 
tion; in protracted cases, however, this tissue may suffer very 
severely. In this event the process is often spoken of as pro- 
ductive or interstitial nephritis. 

Consonant with the etiological factors we distinguish a primary 
and secondary form of acute nephritis, but, except for some 
slight difference in the onset (it being more sudden in primary 
nephritis), the symptomatology is practically the same in both 
varieties. The child complains of backache, headache, nausea 
and chilliness, occasionally vomits, and, in severe forms, shows 

(447) 



communi 

cable 

diseases. 



Parenchy- 
matous. 



Interstitial. 



448 



DISEASES OF KIDNEYS, BLADDER, ETC. 



Edema. 



Other symptoms of grave constitutional disturbance. Not infre- 
quently attention to the illness is not attracted until the appear- 
ance of puffiness of the eyelids, or, especially in infants, the 
occurrence of partial or total suppression of urine with or with- 
out uremic symptoms. Examination of the urine discloses more 
or less marked alteration in its constituents. Chemically the 
urine almost invariably reveals the presence of a variable amount 
^^and^^casS ^^ albumin, and, microscopically, casts of all sorts, especially 
hyaline, red and white corpuscles, epithelium, detritus, etc. The 
urine is usually acid, and its specific gravity high, the latter being. 




Fig. 139. — Acute Hemorrhagic Nephritis. X 350. Small 
and large squamous epitheHum, hyaline casts (at the margin), g, 
^ Finely granular cast, hi, Red blood-corpuscle cast, e, Tubular 

epithelium (arranged in cast form). Here and there are blood- 
corpuscle rings ("shadows" [ghosts]). {Lenhartz and Brooks.) 

of course, most marked when the quantity is very small. The 
secretion of urea is diminished. In severe inflammation of the 
Hematuria, kidneys the urine contains a large quantity of blood (hemorrhagic 
nephritis), and is dark-red or smoky in color. 

As already alluded to, the onset of nephritis often escapes 
detection. This is especially true in the secondary form. Hence 
the importance of systematic examination of the urine during the 
course of acute communicable diseases. It is well to remember, 
however, that not every albuminuria is of nephritic origin. A 
small quantity of albumin and a few casts are not rarely found 
in acute febrile diseases {e.g., in the beginning of scarlatina) 
without kidney lesions and are only transitory in nature. 



NEPHRITIS ACUTA. 449 

Cases running a favorable course begin markedly to improve 
after about two \\'eeks. The albumin diminishes; the urine in- 
creases in quantity, becomes light and clear, and the microscopic ^®°^^° 
abnormal constituents subside. Edema, if present, is slight, and 
usually limited to the eyelids and rapidly disappears with the 
improvement of the other symptoms. 



cases. 




Fig. 140. — Acute Xephritis with General Anasarca in a Child 4 
Months Old. {Sheffield:) 

Less favorable cases are of longer duration. From day to 
day the edema assumes wider dimensions, involving the dorsi of Maiig 
the feet, the legs, the genitalia, and, if not checked, the serous 
eitusion may rapidly fill the abdominal and thoracic cavities. In 
the majority of instances, however, gradual recovery from the 
immediate attack occurs, although in these cases a relapse must 
always be apprehended. 

29 



450 



DISEASES OF KIDNEYS, BLADDER, ETC 



Oliguria 

up to anuria. 

Uremia. 



Another group of cases is characterized by great diminution 
of urine (oHguria) or total suppression and consecutive uremia. 
The latter is manifested by intense headache, dizziness, vomiting, 
dimness of vision up to total blindness, disturbance of hearing, 
slight twitching up to repeated attacks of severe convulsions, 
slow, irregular pulse, dyspnea, somnolence, sopor and possibly 
coma and death. 




Fig. 141. — Same case as Fig. 140. Three weeks later. (Sheffield.) 



Scarlatinal. 



The incipient symptoms of nephritis offer no reliable indica- 
tions as to the further course of the disease. Scarlatinal neph- 
ritis, for example, ushers in with vomiting, intense headache, con- 
vulsions, local or general dropsy, and yet clears up completely 
within two or three weeks ; and, conversely, nephritis may set in 
insidiously, apparently entirely free from any alarming symptoms, 
and, nevertheless, proceed a very protracted course and possibly 
lead to permanent degeneration of the kidney structures. 
Relapse. Furthermore, relapses may complicate matters often when 
recovery is imminent. 



NEPHRITIS ACUTA. 451 

The prognosis, therefore, should always be guarded, even 
though the general condition of the patient is good. Even in 
mild cases untoward complications are apt to supervene. Serous 
effusions in internal cavities are not rare. This is true especially Ascites, 
of ascites, less frequently of pleural or pericardial eft"usions. The 
heart rarely escapes involvement. Hypertrophy of the heart is hypertrophy, 
quite common, and if the nephritis runs a protracted course 
dilatation of the heart may prove a very dangerous complica- 
tion, particularly in view of the secondary pulmonary edema, edema.^^^^ 
which is very prone to occur in such cases, and often prove fatal. 
Extensive anasarca with scanty urine, especially if ascites is 
associated with hydrothorax, greatlv mars the prognosis. As 

, 1- ' ' • ■ • Complica- 

turther complications we may mention uremia, pneumonia, tions. 
edema of the glottis, severe intestinal catarrh, more rarely peri- 
tonitis, pericarditis and endocarditis (more frequent in scarlatinal 
nephritis). Notwithstanding, however, the great array of com- 
plications, immediate death from acute nephritis, especially from 
the primary variety, is not common. The death rate ranges 
between five and twenty per cent. — the variation depending upon 
the primary cause, mode of treatment and severity of the compli- 
cations. A great many patients who survive the acute stage 
remain invalided for life. As wq shall see later, o-radual transi- 

Chronic 

tion from acute into chronic nephritis is not of uncommon occur- course, 
rence. Convalescence is often prolonged for weeks and months, 
and even without permanent injury to the kidneys albumin may 
recur in the urine from time to time for a period of a year or 
two or longer and continue to undermine the child's constitution. 
Every case of nephritis, be it ever so mild, should be taken 
seriously, and kept under strict observation not only during the 
active stage of the aft"ection but for many months after. During 
the acute stage perfect rest in bed should be enjoined and the diet ^^^t. 
limited to bland articles of food free from salt, preferably milk 
in moderate quantity with strained oatmeal or barley, zwieback Restricted 
with sweet butter, stale bread with a little apple sauce, and occa- 
sionally a little chicken soup. The partaking of water should be 
restricted to a few tumblerfuls of A^ichy or lithia water per day. 
As the condition improves the dietary may be augmented by the 
addition of freshly boiled — without salt — vegetables, such as 
carrots, spinach, cauliflower, fresh green peas, etc., stewed fruit, 
and freshly boiled whitefish. The bowels should be kept open Laxatives 
bv an occasional dose of calomel followed bv citrate of masrnesia 



452 DISEASES OF KIDNEYS, BLADDER, ETC. 

and by daily high intestinal irrigation. Where the excretion of 
urine is greatly reduced and the dropsy marked, energetic 
measures to reheve the kidney should be instituted without delay. 
This should be attempted, not, as is frequently advised, by means 
of active diuretics — which only help to increase the renal con- 
gestion — but by stimulating the activity of the skin and allaying 
Hot baths; the irritation of the kidney. For this purpose we resort to hot 
flushing, packs (105° F.), hot baths (103° F.), and hot colon flushing 
(110° F.). These may be repeated every six hours. Perspira- 
tion may be stimulated by small quantities of hot water, or hot 
lemonade. In hemorrhagic nephritis small doses of ergot act 
beneficially. Camphor will be found valuable to counteract 
Camphor, collapsc, and should be administered hypodermatically in the 
form of sterilized camphorated oil. Excessive irritability of the 
nerve system should be combated by means of the bromids and 
chloral. 

By carefully following the aforementioned directions, uremia 
Arrest of ig of rare occurrence. Uremic convulsions should be controlled 

uremia. 

by chloroform inhalation, hypodermatic injection of morphine and 
atropine (for a child two years old gr. %2 of morphine, and gr. 
%oo of atropine, if necessary to be repeated once after two 
hours), and, where these therapeutic measures fail, by lumbar 
puncture. 

Children recovering from nephritis should not be exposed to 

After-treat- the ill cffccts of Overfeeding, overexertion, and exposure to 

marked atmospheric changes. They should wear light woolen 

underwear, and, financial means permitting, should spend the 

winter following an acute attack of nephritis in a warm climate. 

To overcome the remaining anemia, iron and cod-liver oil will 
be found of service. 

NEPHRITIS CHRONICA. 

In the majority of instances chronic nephritis develops as a 
sequel of the acute affection of the kidneys. The parenchyma 
or interstitial tissue or both remain permanently impaired. On 
the one hand, we may find the kidneys greatly enlarged, the 
cortical portion increased in volume, its surface white or pale- 
Large, white yellow — large white kidney or parenchymatous nephritis. On 
kidney. ^^^^ other hand, the whole organ is reduced in size, the capsule 
firmly adherent, and the surface irregular and nodular — the 
^kidi^ey^ granular or cirrhotic kidney, or interstitial nephritis. Amyloid 



NEPHRITIS CHRONICA. 453 

degeneration is another form of chronic nephritis in childhood. 
It is usually associated with amyloid degeneration of the liver and 
spleen, and ordinarily occurs secondarily to suppurative processes 
of the bones or joints. Occasionally chronic nephritis is 
encountered in connection with congenital malformations of the 
kidneys, or as result of hereditary syphilis, tuberculosis, and 
heart disease. 

In the early stages of chronic nephritis the diagnosis rests 
principally upon the chemic and microscopic findings in the Findings in 

T 1 . . 1 .... urine. 

urme. In parenchymatous nephritis the quantity of urine is 
normal or diminished, the specific gravity normal or increased, 
the albumin content high, and the color cloudy, brownish yellow 
or bloody. In interstitial nephritis the quantity of urine is 
increased, the specific gravity low, the albumin content low (occa- 
sionally no albumin), and the color clear, and pale. In amyloid 
degeneration the urine is rich in serum-albumin and globulin. 
Its quantity is often increased. Casts in the urine are present 
in all varieties. 

With further advance of the disease, the appearance of pro- 
found anemia, digestive and respiratory disturbances, local and Anemia, 
general dropsy, and cardiac debility readily discloses the under- 
lying condition. Toward the end of life the symptoms resemble ^^^^oj^g 
greatly those of non-compensating heart disease. 

Parenchymatous nephritis offers the worst prognosis, death 
usually setting in within a year from the appearance of the 
secondary symptoms. The course of interstitial and amyloid 
nephritis is much more protracted and cases of amyloid kidney 
are on record which markedly improved on removal of the 
suppurative bone affection, but complete recovery is practically 
out of question. 

Under suitable treatment (except in the parenchymatous 
variety) life may be prolonged for many years. As in acute ^fg\*"^^^^ 
nephritis, the diet should be free from salt, but otherwise more 
liberal. Older children may live on a mixed diet; the following 
food-stuffs, however, are to be exempt from the list : Liver, ham, 
brains, kidneys, beef -juice and beef -extract, coffee, liquors and J'e^a^vofded 
spices. All meats, eggs and fish should be taken sparingly. 
Whenever possible, the child should live in a warm climate. Out- 
door life and very light exercise are desirable. Daily warm baths 
with gentle massage act beneficially. With appearance of dropsy, 
dyspnea, or other grave symptoms, the patient should be put to 



Hematinics 



Hematuria; 
pyuria. 



454 DISEASES OF KIDNEYS, BLADDER, ETC. 

Rest, bed and treated in the manner outlined under "acute neph- 
ritis"(g. v.). 

Hematinics, in small doses, and other tonics in the form of 
cod-liver oil, nux vomica and digestants are in order as necessity 
arises. Excessive dropsical effusions should be relieved by active 
catharsis, alkaline diuretics, and heart stimulants, in addition to 
the therapeutic measures recommended in dropsy accompanying 
acute nephritis. 

NEPHROLITHIASIS 

(Stones in the Kidney; Renal Calculi). 

Sudden Renal calculi in children give rise to symptoms identical with 

attacks. |-|-^Qgg observed in adults. Thus, sudden attacks of pain in the 
lumbar region, radiating downward along the course of the 
ureters, groins, and, in the male, to the testicles. The attacks 
are usually associated with nausea, vomiting and convulsions and 
often collapse. The urine is passed frequently, in small quan- 
tities, and contains blood- and pus-cells. The urine, however, 
may appear normal if it is excreted from the healthy kidney only, 
or there may be complete anuria if both ureters are simultaneously 
obstructed. Where the stones remain impacted in the ureter, 
the condition is apt to become very grave in consequence of 
nephrosis, superveuing hydronephrosis, pyonephrosis or pyelonephritis. In 
this event we are often obliged to resort to surgical interference. 
Otherwise symptomatic treatment usually suffices to effect marked 
improvement or even a cure. Alkalies should be administered in 

Specific ... . . . ,. . , , 

medication, uric acid concrcmcuts, sodium phosphate m oxalic acid, and 
citric acid and acetic acid in phosphatic concrements. The diet 
should be bland (avoidance of meat), and metabolism enhanced 
by digestives, mild laxatives, moderate exercise, hydrotherapy 
Anodynes, and iiiassagc. To relieve an attack we resort to anodynes 
(morphine and atropine hypodermatically), hot baths and hot 
poultices. 

An X-ray examination is often decisive in the diagnosis 
between nephrolithiasis and appendicitis, with which affection the 
former may be confounded. 

PYELITIS, PYELONEPHRITIS, PYELONEPHROSIS. 

Inflammation of the pelvis of the kidney and contiguous 

Renal structurcs with consecutive suppuration may occur as a result of 

stones, direct injury of the lining mucous membrane, e.g., renal stones ; 



HEMOGLOBINURIA. 455 

as a sequel of infectious diseases, such as scarlatina, diphtheria, 
variola, or pyemia, or by extension of a suppurative process from 
the neighboring tissues or organs, e.g., perinephritic abscess, 
cystitis, colicystitis, purulent vulvovaginitis. It is also met in coiicystitis. 
connection with congenital malformations of the kidneys or 
ureters, renal tuberculosis and tumors. The pyelitis may be 
unilateral (when due to a local cause) or bilateral. 

The symptomatology of pyelitis varies greatly with the cause 

Riffors 

and the course it pursues. In acute cases there are rigors, high fever, ' 

and fluctuating temperature, frequent and scanty urination, pain 

in the lumbar region, and, above all, pyuria. The morphological 

constituents of the urine vary with the degree of involvement of 

the kidneys, ureters and bladder. Cases proceeding a chronic 

course are ordinarily free from febrile excursions. Pyonephrosis Tumefaction. 

often gives rise to a palpable tumor. There are a number of 

other symptoms which vary with the primary or secondary 

disease. 

Where the cause is removable, and prompt treatment is insti- 
tuted, the pyelitis may entirely disappear and leave the kidney 
uninjured. Otherwise the prognosis, as to complete recovery, is 
bad. The prognosis as to life depends entirely upon the exciting 
cause and complications, nephritis and exhaustion forming the 
principal sources of danger. 

The aim of treatment, therefore, should be to avoid the latter „ 

Prevention 

by earlv elimination of the fundamental disease, and prevention o^ reeur- 

-' ' . rence. 

of recurrence of attacks. The details of such treatment are fully 
outlined when speaking of the diseases in question. Otherwise 
the treatment is symptomatic. The urine should be rendered 
alkaline, and as aseptic as possible. This is best accomplished operation, 
by a liberal supply of water, alkaline diuretics and hexamethyl- 
enamin. Pyonephrosis calls for surgical interference. 



HEMOGLOBINURIA. 

Hemoglobin or methemoglobin in the urine is occasionally 
observed in infants and older children, either as a result of Jo^i^ 

' _ drugs. 

poisoning by phosphorus, potassium chlorate, carbolic acid, etc., or 
in connection with severe burns, acute and chronic infectious dis- 
eases, such as exanthemata, malaria, and hereditary syphilis. The 
urine is mahogany-brown or black in color, greatly resembling ^^^^^ 
bloody urine. JMicroscopically, however, it shows the presence 



456 



DISEASES OF KIDNEYS, BLADDER, ETC. 



No blood, of blood coloring substance only, but no blood-corpuscles. The 
spectroscope discloses bands of hemoglobin. The attacks of the 
hemoglobinuria are of brief duration (sometimes last but a few 
hours), and are manifested by debility, chilliness, cyanosis, and 
sometimes high fever. These symptoms disappear as the urine 
clears up. Occasionally the hemoglobinuria appears in paroxysms 
Paroxysmal, {paroxysmal hemoglobinuria) without any discernible cause or 
after exposure to cold or undue fatigue. 

By rest in bed, liberal supply of liquids, and attention to the 
exciting causes, the hemoglobinuria subsides without any serious 
consequences. (See also "Epidemic Hemoglobinuria," page 182.) 

ORTHOTIC, CYCLIC OR FUNCTIONAL 
ALBUMINURIA. 

As the term (orthotics standing up) indicates, the disease is 
absent^wh'en characterized by the presence of albuminuria after the patient 
^^at^rest ^^^ ^^^^ ^P ^^^ arouud, and by its absence while he is perfectly 
at rest. It is observed especially in delicate children of from five 
to fifteen years old, and seems to have nothing in common with 
organic kidney disease. A family predisposition has been traced 
in some cases, and a history of scarlatina and diphtheria in 
others. The urine is free from abnormal morphological con- 
stituents — the opposite being the case in true renal disease. 

Under suitable treatment, which is essentially the same as in 
the early stage of chronic nephritis, the albuminuria often dis- 
appears for a time, but may return after a shorter or longer 
interval (intermittent form). Notwithstanding the continuance 
of the albuminuria for many years, the system is very little 
affected by it, and the prognosis as to life is good. Transition of 
cyclic albuminuria into nephritis, however, is on record. 



TUMORS OF THE KIDNEY. 

Aside from tuberculosis and syphilis, which have been dis- 
Benign. cusscd clsewhcre, the kidneys are occasionally the seat also of 
benign and malignant neoplasms. The benign tumors (adenoma, 
fibroma, lipoma, cysts, etc.), owing to their very slow growth, 
generally escape observation, and are often found post mortem in 
children who, during life, never manifested signs of kidney 
Malignant, growths. To a great extent this is true also of malignant tumors 
(sarcoma, carcinoma, myosarcoma and adenosarcoma) in their 



TUMORS OF THE KIDNEY. 457 

early stages of development, since the tumor is barely palpable 
and the two additional characteristic symptoms of malignant kid- 
ney growths (i.e., hematuria and cachexia) are present in only Hematuria. 
a small percentage of such cases and is encountered also in a 
number of other wasting diseases. 

In the beginning the tumor may be felt only in the loin ; within 
a few months, however, it is found to have spread in all direc- 



-ar'«» 




Fig. 142. — Sarcoma of the Kidney (child 27 months). The tumor 
occupied almost the entire abdomen. (Sheffield.) 

tions, displacing the liver, spleen, lungs and intestines, and to paipabie 
occupy the entire abdominal cavity (see Fig. 142). Not rarely ^^^^' 
it forms secondary metastases in the other kidney, in the liver, 
spleen, intestines and retroperitoneal glands, and, by pressure 
upon the ureter, may give rise to hydronephrosis. 

Unless operated upon early — which treatment should invari- 
ably be recommended — -the children usually succumb to progres- 
sive emaciation and exhaustion within about a year from the 
time the tumor makes itself felt. As the majority of growth is 
of antenatal origin nothing can be done in the way of prophylaxis. 



Metastases. 



Early 
operation. 



458 



DISEASES OF KIDNEYS, BLADDER, ETC 



Primary. 



Secondary. 



Colicystitis 



Extension 
upward. 



Strangury. 



Blood. 



Acid urine 
in coli- 

cystitis. 



CYSTITIS. 

Inflammation of the bladder may occur as a primary or 
secondary disease. Primary cystitis is extremely rare in children, 
more especially in infants, since the principal cause — direct 
mechanical injury of the mucous membrane by surgical instru- 
ments or other foreign bodies — is but very rarely operative in 
young children. On the other hand, secondary cystitis is of com- 
paratively frequent occurrence, and may arise from a great 
many causes, the most important of which being infectious dis- 
eases (diphtheria, scarlatina, etc.), kidney and bladder diseases 
(calculi, pyelitis, tuberculosis, tumors, etc.), cerebrospinal affec- 
tions (atony and overdistention of the bladder with consecutive 
inflammation by decomposed urine), intestinal diseases (invasion 
of the bladder by colon bacillus — colicystitis), and diseases of 
the vagina and urethra, especially of gonorrheal origin (by exten- 
sion of the inflammation). Cystitis may follow chemical irrita- 
tion (overdoses of cantharides, balsams, hquors, etc.), exposure 
to cold (sitting on cold stones, etc.) and direct external violence. 

The lesions in the bladder may range from simple localized 
redness to extensive ulceration of the mucous membrane and 
pseudomembranous deposit. In cases of long standing the inflam- 
mation is prone to spread to the ureters and kidneys. In chronic 
cystitis the mucosa assumes a gray, pigmented color, becomes 
greatly hypertrophied, and covered by mucopurulent masses. 

In accord with the severity and extent of the lesion cystitis 
may be manifested by mild or grave symptoms. The latter are 
most pronounced in primary cases, in those associated with infec- 
tious diseases (e.g., diphtheria), and in infection by the colon 
bacillus. In mild cases the symptomatology consists of painful 
and frequent micturition, sensitiveness over the region of the 
bladder, sometimes rectal tenesmus and excoriation of the 
urethral orifice and of the contiguous structures. The urine is 
voided in small quantities, sometimes only a few drops at a 
time, and contains mucous shreds, bladder epithelium, pus- 
corpuscles, blood-corpuscles, and numerous bacteria. The urine 
is neutral or alkaline, cloudy and dark red, and may contain 
pieces of membrane if the cystitis is of diphtheritic origin. In 
colicystitis the urine is usually acid in reaction, and in addition 
to the aforementioned constituents presents traces of albumin. 
The constitutional symptoms are slight. Severe forms of cystitis, 
especially colicystitis, give rise to marked constitutional disturb- 



CYSTITIS. 459 

ances, such as vomiting-, chills, irres^ular fever, and sometimes po^^^i", 

' &' ' & tutional 

convulsions (particularly if anuria exists). The local symptoms symptoms 

^^ ■^ ^ . especially m 

also are much more pronounced. If left to run its course, the coiicystitis. 
condition is not rarely aggravated by the concurrence of nephritis, 
which ma}' lead to a fatal termination. 

As it is not always possible in the beginning to foresee the 
eventual course of the disease, and as the tendency even of mild 
cases towards chronicity is great, it is essential not to trifle with 
the afifection, but promptly to employ all such therapeutic 
measures as will insure its early arrest and ultimate cure. The Restricted 
patient should be put to bed and on a mild diet (milk and Vichy ^'^^'^' 
water, milk-gruel, chicken soup, eggs, cereals and bread). All 
spices, alcoholic beverages, coilee and tea should be prohibited. 
To relieve pain, hyoscyamus is the remedy par excellence. It may Hyoscyamus. 
be combined with acetate of potash and small doses of hexa- 
methylenamin. A\'arm Priessnitz compresses are also of value. 
Where the pain persists, a suppository of codeine and extract of ^°*^®^^®- 
belladonna will be found to act well. With subsidence of the 
acute symptoms — usually after a week or two — it is advisable 
to begin to irrigate the bladder (under the most careful aseptic 
precautions) with a warm solution (V2000 o^ ^iooo) of nitrate of ^"^^*^^°^- 
silver or potassium permanganate. From half a pint to one quart 
of the solution may be used for each treatment, and the irrigation 
may be repeated once a day or every other day. 

Under this method of treatment the majority of cases of 
cystitis will recover in from four to eight weeks — provided, of 
course, the primary cause can be detected and removed. 

Transition of acute cystitis into chronic is bv far less common 

. . .' . . Tendency to 

in children than in adults. The possibility of the disease being chronicity. 

tubercular should always be borne in mind (see page 370). 

B Kalii acetatis 3j [ 4 

Ext, hyosciami fl gtt. xvj j 1 

Inf. iivas ursi §j | 30 

Aq. anisi q. s. ad 3ij 1 60 

M. Sig. : 3j, in water, every three to six hours for a child 3 vears 
old. 

IJ Hexamethylenaminae gr. xvj | 1 

Natrii benzoatis 3ss I 2 

Ext. belJadonn^_ fl gtt. iv | 0.3 

Mucilaginis ulmi 3iv [ 15 

Aq. f oeniculi q. s. ad f §ij | 60 

M. Sig. : 3j, in water, every four hours for a child 3 years old. (In 
coiicystitis.) 

See also "Biologic Therapeutics." page 96. 



460 DISEASES OF KIDNEYS, BLADDER, ETC. 

VESICAL CALCULI 
(Stones in the Bladder). 

Bladder stones sooner or later give rise to the following 

characteristic symptom-complex: Vesical and often rectal tenes- 

strangury. mus, strangury, partial or complete retention or incontinence of 

Interrupted Urine, difference in the force of the stream of the urine with 

urine, change in posture of the patient, and, after a protracted course, 

the usual symptoms of cystitis {q.v.). The urine may reveal the 

presence of either phosphate stones (phosphate and carbonate of 

lime, magnesia), oxalate stones (oxalate of lime) or urate stones 

(uric acid). Small concrements may escape with the urine; 

Impacted large ones, however, are apt to become impacted in the urinary 

canal and cause intense pain and grave nervous symptoms, e.g., 

convulsions. 

The diagnosis is based upon the aforementioned manifesta- 
tions, upon feeling the stone in the bladder by rectal digital 
examination or by a sound introduced into the bladder, and upon 
x-ray. an X-ray examination. 

The development of stones may frequently be prevented by 

a bland diet (no meats), ample supply of water, and attention to 

Anodynes, the bowcls. In cascs of long standing operative interference is 

indispensable. Painful symptoms are relieved by means of 

hyoscyamus. 

SPASMUS VESICA, DYSURIA, ISCHURIA 
(ANURIA). 

These conditions are etiologically correlated. In the majority 

Calculi, of instances they are the result of vesical calculi, blood-clots 

obstructing the urinary flow, phimosis, paraphimosis, vulvitis and 

Uric acid vaginitis, cystitis, uric acid infarcts (in the newly born), sudden 

chilling of and injury to the lower portion of the abdomen, nerve 

affections (functional or organic), and priapism (in the male). 

The treatment varies with the original cause. An attack is 

usually relieved by a hot bath, a suppository of codeine and 

extract of belladonna, and the administration of diuretics, such 

as sweet spirits of niter and triticum repens. 

B Kalii citratis 3j 1 4 

Ext. hyosciami fl., I 

Ext. triticum repens fl aa 3ss 1 2 

Syr. simplicis 3iv | 15 

Aq. destil q. s. ad f Sij | 60 

M. Sig. : 3j, in water, every three to six hours for a child 3 years 
old. 



ENURESIS. 461 



ENURESIS. 



Atony. 
Spasm. 



It is customary to distinguish two varieties of enuresis in 
children : Enuresis diurna and enuresis nocturna. The first Diurna 

and 

variety is but rarely met in children, capable of differentiating nocturna. 
right from wrong, excepting in those who willfully "wet" them- 
selves, or in congenital deficiencies. The second variety, on the 
other hand, occurs in a very great number of children, regardless 
of age, sex, intelligence or social conditions. The child may wet 
itself one or more times every night, or at intervals of days or 
weeks ; in the last event, it is usually due to willfulness, excessive 
drinking, or faulty diet. An inherited tendency and neurotic • 
disposition seem to play an important part in the causation of 
enuresis, although the latter may exist independently of either of 
these causes in children apparently perfectly healthy. 

The causes of enuresis may conveniently be arranged in two 
classes : — 

1. FUNCTIONAL. 

The cases due to functional causes are purely neurotic in 
character. The urine is voided involuntarily either owing to 
atony of the sphincter vesicae, or to a spasmodic condition of the 
detrusors vesicas. In both cases there is a functional disturbance 
in the nervous apparatus of the urinary system. It is usually 
found that enuresis due to atony is associated with general 
debility, and often follows a protracted course of an exhausting 
disease. On the other hand, enuresis due to ''spasm" is usually 
found in children who are irritable, who present an increased 
patellar reflex, are easily frightened, are subject to pavor noc- 
turnus and similar nervous conditions. 

2. ORGANIC. 

The greater number of cases arise from organic troubles. 
The child may suft'er from : — 

Organic disease of the spinal cord; cystitis; phimosis or para- loc^i and 
phimosis (in the male) ; hypertrophy of the clitoris or adhesion |geSons. 
of the prepuce (in the female) ; masturbation; undescended 
testicle ; hernia ; worms ; vesical and renal calculi ; tumors in 
the bladder ; excessive quantity of lithiates or phosphates ; con- 
stipation and accumulation of feces ; epi- or hypo-spadia ; fissure 
ani ; vulvovaginitis ; diabetes, gonorrhea, simple or gonorrheal 
proctitis. 



462 DISEASES OF KIDNEYS, BLADDER, ETC 

In the treatment of enuresis it is of greatest moment to 
systematically examine the patients for the organic diseases 
just enumerated and to endeavor to eliminate every symptom 
suspicious of organic disease. In absence of organic causes there 
is evidently a neurotic case to be dealt with and the treatment 
must be adopted accordingly. Patient if old enough should be 
instructed not to abstain from micturition when called upon 
SiDft by nature to do so, and small children should be trained to void 
urine about every three hours, and not be permitted to withhold 
the urine for a longer period. This is very important, for it is 
often overdistention of and decomposition of the urine in the 
bladder that prove the primary cause of the subsequent secondary 
etiological factors (atony or hyperesthesia of the bladder, pres- 
ence of concretions, cystitis, etc). It is also advisable to en- 
courage drinking of water in cases of enuresis due to concretions, 
cystitis, or gonorrhea, but to forbid it in other cases. The 
patient is not to be permitted to sleep on his back, and it is often 
of advantage to raise the foot of the bed in such a manner that 
the child's trunk and head lie deeper than the pelvis. 

In enuresis due to atony a general constructive treatment is 
indicated. Plenty of good nourishment, change of air, cold spinal 
douches, medicinal tonics and electricity are usually effective in 
bringing about a cure. A moderate galvanic current is usually 
best; one pole is applied to the symphysis or rectum, the other to 
the perineum. The following mixture is often very serviceable : 

IJ Ext. ergotas 7.^ f 3ii j | 12 

Ext. rhus tox fSj I 4 

M. -Sig. : Five to 10 drops every four to six hours to a child 6 years 
old. 

In incontinence of urine associated with hyperesthesia of the 
Antispas- coUum vesicse or spasm of the detrusors, an antispasmodic 

modics. ^ . • 1 r 

treatment is indicated, consisting of hot sitz-baths, avoidance of 
irritating food or drinks and the administration of either ext. 
belladonna or hyoscyamus. I usually prescribe the following: — 

I^ Ext. hyoscyami 3ss j 2 

Natrii bromidi ^j I 4 

Aquae anisi .^i I 30 

Syrupi simplicis q. s. ad l\] 1 60 

M. Sig. : One teaspoonful everv four to six hours to a child 6 years 
old. 

Counterirritation by means of sinapisms over the lumbo- 
sacral regions often does well, and if everything fails this class 



Tonics. 



VULVOVAGINITIS. 463 

of cases is occasionally cured by gradual dilatation of the 
posterior urethral canal. 

As to the treatment of enuresis from organic causes, nothing 
more will be said here than that each case must be treated as an 
individual disease in accordance with its etiology. 

Remonstrance, severity and moral suasion will often cure Moral 
cases of enuresis of nervous origin or those which continue from 
mere habit long after removal of the original cause. 

VULVOVAGINITIS. 

Notwithstanding recent advances in bacteriology and micros- 
copy, the profession is not as yet in accord as to the exact 
nature of vulvovaginitis in children. Some physicians still doubt 
the fact that most cases are due to the gonococcus of Neisser and 
are highly contagious, but tenaciously cling to the ''scrofulous" 
theory of the disease and recommend tonics to combat it. As a 
result, innumerable cases run at random, leaving sources of 
contagion in public schools and baths, homes, and hospitals, with 
apparently no one in authority to check the further spread of the 
affection. 

Clinically vulvovaginitis may be classified as follows : — 

1. Catarrhal vulvovaginitis, which is generally due to (a) 
lack of cleanliness or (^) chemical irritation. 

2. Traumatic vulvovaginitis, which is caused by (a) mastur- 
bation (?), (b) mechanical injury, or (c) indecent violence. 

3. Parasitic vulvovaginitis, which is due to (a) oxyurides, 
(6) saprophytes, or (c) pathogenic bacteria, especially the gono- 
coccus. 

The first variety of vulvovaginitis is usually met in poorly Catarrhal, 
nourished children of overcrowded tenement districts, who receive 
a thorough cleansing on very special occasions only. As a rule, 
these cases begin with vulvitis, the vagina becoming gradually 
involved by extension of the inflammation. Catarrhal vulvovagi- 
nitis is not always limited to the very poor, and the physician 
need not hesitate to suspect dirt even under the most elaborate ^^^^" 
apparel. 

This variety of vulvovas^initis is also frequently observed in chemical 

, , , . irritation. 

children whose genitalia are exposed to excessive wetting by 
irritating, decomposing secretions, and excretions — sweat, diar- 
rheal stools, hyperacid urine — and to undue pressure and friction. 



464 DISEASES OF KIDNEYS, BLADDER, ETC. 

In former years, when bicycle riding was a national fad, vulvo- 
vaginitis was not rarely met in assiduous bicycle riders, undoubt- 
edly as a result of the aforesaid causes. 
Traumatic. The Consideration of the second, traumatic, variety of vulvo- 
vaginitis does not, strictly speaking, belong to the domain of 
medicine, except as regards the treatment. We are dealing here 
with faulty habits and criminal traits which deserve serious atten- 
tion on the part of teachers, the clergy, and jurists. However, 
as it is the physician who is usually consulted first, a few points 
of information will prove useful to him, particularly as a warning 
not to be too hasty in expressing a positive opinion. 

I believe that entirely too much stress is beinp^ laid by some 

Mastur- , , ^ . , . , . / ^ 

bation. authors upon masturbation as an etiological factor of vulvo- 
vaginitis. It is much more probable that masturbation is a result 
rather than a cause of it, the undoubtedly existing irritated state 
of the erectile tissue inducing that bad habit. 

The presence of foreign bodies in the vagina is not infre- 
quently found to be the cause of vulvovaginitis. While some 
girls will introduce foreign bodies in the vagina with lascivious 
bodies, intent, the great majority of foreign bodies, e.g., safety pins, will 
find their way in the vaginal canal accidentally, and should always 
be looked for, particularly in cases of long standing. 

Occasionally cases of vulvovaginitis are encountered which 
are the result of indecent violence. The purulent discharge is 
either non-gonorrheal or gonorrheal, the latter only if the criminal 
Rape. ^j^Q attempted rape had at the time been suffering from gonor- 
rhea. It is well to remember that not every case of vulvo- 
vaginitis reported to be due to rape is really such, and unless the 
vaginitis is associated with actual penetration of the hymen and 
concomitant signs of inflammation due to violence, the physician 
should be very cautious in venturing a positive opinion. 

Saprophytic micro-organisms are responsible for a great 
number of cases of vaginitis. To them is attributable the vagini- 
Parasitic. ^-^ ^^^ infrequently met after acute exanthema tous diseases (with 
or without desquamation) and in conjunction with divers forms 
of cutaneous eruptions. The same cause accounts also for the 
vaginitis observed in strumous and debilitated children suffering 
from purulent discharges from the nose, ears, etc. Indeed, the 
number of cases of saprophytic vulvovaginitis would by far 
exceed all those arising from all other sources collectively were 
it not for the antag^onistic action of the bacillus of Doederlein 



VULVOVAGINITIS. 465 

which normally inhabits the vagina. This vagina bacillus, which 
is anaerobic and may be cultivated on ordinary media, produces 
lactic acid during its growth, a quality to which is due the 
presence of lactic acid in the healthy vagina. In its presence 
saprophytes, as well as numerous other bacteria, such as the saprophytic. 
staphylococcus and streptococcus, are unable to develop, and 
within a short time perish. Gonococci, however, do not yield as 
promptly to the destructive effect of the vagina bacillus; hence 
the frequency with which gonorrheal vulvovaginitis is met, not- 
withstanding the resistance offered to the entrance of gonococci 
into the vagina by the stratified squamous epithelium Hning it. 

As stated before, contamination of the vagina by criminal 
assault is comparatively very rare. Much more frequently 
infection takes place by voluntary sexual act or accidentally. 
Little girls sleeping with their parents, elder brothers, sisters, or 
nurses suff'ering from gonorrhea, may contract the disease by 
coming in contact with soiled bed-clothes, cotton pads, or other 
articles used for cleansing purposes. 

Gonorrheal vulvovaginitis runs a more or less virulent course, Gonorrheal, 
and in hospitals and asylums where many children are con- 
gregated in comparatively close quarters, and frequently make 
common use of infected bathtubs, toilets, etc., the disease is very 
apt to become epidemic as well as endemic. In one epidemic 
under my care, in an orphan asylum, comprising over one 
hundred cases, it required many months of very active treatment 

. ~. . . ... , . , Prophylaxis. 

to eradicate the affection. Arrest of further spread of the 
gonorrhea was not eft'ected until every patient was isolated and 
kept in bed for several weeks. x\ biweekly examination of every 
female inmate of the institution (including the nurses in charge) 
for vaginal discharge was continued for several weeks after dis- 
appearance of the last case of vaginitis. 

Such procedures form the main prophylactic measures against 
the disease. Of course, the patients must be restricted from the prevention 
common use of chambers, bedding, bathtubs, etc. In hospitals 
and asylums, admitting physicians should be particularly careful 
to exclude all children having a purulent vaginal discharge, unless 
provisions be made for the isolation and treatment of such cases. 
This point is well worthy of consideration, as it would greatly 
aid in checking further transportation of the disease. As the 
majority of cases of vulvovaginitis is observed among school- 
children, a suggestion to the health authorities is, perhaps, in 

.30 



466 



DISEASES OF KIDNEYS, BLADDER, ETC 



Isolation. 



Complica- 
tions. 



Prevention 
of gonor- 
rheal 
oplathalmia. 



Danger of 

forcible 

douching. 



Gonorrheal 
proctitis. 



order, viz., to instruct the school inspectors to pay more attention 
to the detection and isolation of the cases of gonorrhea in chil- 
dren than they do now. 

As gonorrhea in adults, that of children presents a marked 
tendency toward grave complications. Among 148 cases under 
my care, the following serious complications were observed : 
Purulent ophthalmia, 7 ; local peritonitis, 4 ; proctitis, 3 ; arthritis, 
4; adenitis, 12. Several cases of pyosalpinx, endocarditis, and 
pleuritis are on record. However, the more familiar one becomes 
in eradicating it, the less numerous will become the complications 
and sequelae in his new cases. 

After extensive experimenting I found that gonorrheal 
ophthalmia can best be prevented by frequent cleansing of the 
genitalia and hands of the patients, and by the employment of a 
large, tightly fitting vulvar pad. The latter should be changed 
for a clean one at least every three hours. The child should wear 
one-piece night-draw^ers during the night as well as day. The 
ophthalmia may sometimes be arrested in its incipiency — I suc- 
ceeded in two cases — by instillation of silver solutions after 
Crede's method. In view of the unusually rapid progress of the 
ophthalmia, unfortunately, it is not often that the physician has 
the opportunity to resort to the prophylactic measures, and 
nothing else remains but to treat the disease actively and skillfully, 
and, if not already involved, to endeavor to save the other eye 
from the dreadful infection. 

Involvement of the uterus and adnexa secondarily to gonor- 
rheal vulvovaginitis in most instances results from injudicious 
use of douches by forcing the vaginal discharge upward into the 
uterus. Fallopian tubes, etc. The treatment therefore should 
not be intrusted to the inexperienced. 

I believe that I am entitled to the credit of having been the 
first to call attention (American Medico-Surgical Bulletin, May 
30, 1896) to the occurrence of gonorrheal proctitis as a compli- 
cation of vulvovaginitis. The rarity with which this complica- 
tion is observed, notwithstanding the constant exposure of the 
anus to the gonorrheal vaginal discharge, would seem to prove 
the comparative immunity of the skin and mucous membrane 
of the anus and rectum to gonorrheal infection. Moreover, 
proctitis usually does not develop until late in the course of the 
vaginitis, i.e., until the skin of the anus and the adjacent struc- 
tures has become abraded and denuded by the continued irrita- 



VULVOVAGINITIS. 467 

tion of the vaginal discharge, or by scratching for the reHef of the 
not infrequently accompanying intense itching. 

The diagnosis of gonorrheal proctitis is rendered positive by 
the presence of the gonococcus in the mucopurulent stools. 

Like the former complication, arthritis, the so-called gonor- Arthritis. 
rheal rheumatism, also develops late in the course of vulvo- 
vaginitis. In the majority of cases the inflammation is limited to 
one joint, usually that of the knee, and occasionally ends in sup- 
puration and ankylosis. 

Inguinal adenitis is quite a frequent complication. The 
glandular enlargement may increase up to a well-marked bubo. 
It sometimes suppurates as a result of an additional infection by 
pus microbes. 

The differential diagnosis between the different varieties of Differential 
vulvovaginitis can readily be made by bearing in mind the 
previously mentioned classification. No examination should be 
considered complete without a very careful microscopic scrutiny 
of the vaginal discharge. In doubtful cases a culture will settle 
the diagnosis. » Furthermore, it is well to remember that several 
etiological factors may be operative in the production of the 
vaginitis in one and the same patient. Hence, the finding of pin- 
worms, for example, in the vagina should not lead us to conclude 
the absence of gonococci. 

The treatment of vulvovaginitis varies greatly with the cause. 
Non-gonorrheal cases usually yield promptly to removal of the 
etiologic factors (e.g., foreign bodies) and to cleansing of the cleanliness. 
genitalia with salt, boric acid, or sulphocarbolate of zinc solu- 
tions. Gonorrheal vulvovaginitis should be treated by instillation 
into the vagina (through a soft-rubber catheter) once a day or 
every other day of half an ounce of a 2 per cent, to 5 per cent, 
solution of nitrate of silver, followed by neutralization with salt Nitrate of 

silver. 

water. After subsidence of the active symptoms douches with 
mild antiseptics will suffice. 

It is well to remember that recurrence of the affection after Tendency to 

recurrence. 

a period of latency is frequent even under the most careful 
method of treatment. No case of gonorrheal vulvovaginitis, 
therefore, should be considered cured unless three or more 
thorough microscopic examinations of the vaginal discharge prove 
the absence of gonococci and pus. 



468 DISEASES OF KIDNEYS, BLADDER, ETC. 

MASTURBATION 

(Onanism, Thigh-friction). 

Production of venereal orgasm by hand, or other unnatural 
means, is a very common vice among school-children, who usually 
acquire the vicious habit from older playmates, or erotic 
governesses, etc. 

Occasionally masturbation is observed in younger children 

Thigh and even in infants. The latter may be seen to rub their thighs 

friction, ^g^jj^s^ gg^(.]-j other or against the bosom of the nurse, or to exert 

peculiar rocking motions and fall back in a more or less marked 

state of exhaustion. 

The effects of masturbation vary with the frequency and 
duration of the habit and the psychical condition of the child. In 
Effects the majority of cases masturbation produces physical and mental 
^auon' debiHty, especially depression of spirits, headache, palpitation of 
Suspicious the heart and emaciation. In boys we may suspect masturbation 
symp oms. ^^ excessivc clongatiou of the penis, in girls by the presence of 
vulvitis, and often stretching of the hymen. Boys are apt to 
suffer from nocturnal seminal emission and later also impotence. 
Removal of In remedying this evil, it is essential to remove all local sources 
of irritation, such as phimosis, hypertrophy of the clitoris, pin- 
worms, etc. Infants should be restrained from practising the bad 
habit by mechanical devices (separation of the thighs, tying of 
the hands). Older children should be placed under proper 
Surveillance, survcillance and in suitable spiritual surroundings (change of 
school; nurses !). The general health should be improved by out- 
door exercise, cold shower baths, and by a nutritious but bland 
Tonics, diet (no liquors). Bromids are indicated to subdue sexual 
excitement. Dime novels should be eliminated from the child's 
reading room. 

GANGRENE OF THE GENITALIA. 

Diphtheria Vulvae, Noma Vulvae. 

Gangrene of the genitalia (vulva, penis, scrotum, etc.) usually 
develops secondarily to grave local inflammatory processes in the 
vicinity. More rarely it is primary in nature (after too liberal 
Drugs; use of Strong antiseptic dressings in open wounds, e.g., carbolic 
diphSieria! acid gangrene in circumcision; the result of direct violence, e.g , 
stuprum) or occurs in connection with diphtheria, dysentery, 
typhoid, and similar affections. 



MEXSTRUATIO PR.ECOX. 469 

Whatever the cause, the prognosis is always very serious, 
fatal termination usually taking place within about ten days from 
the onset, unless we succeed in checking the spread of the 
gangrene by early cauterization or excision of the affected part. 
Diphtheria antitoxin is deserving of trial. SJmoxfn!^ 



Cauteri- 
zation. 




Fig. 143. — Precocity (child 8 years old). {Sheffield.) 

MENSTRUATIO PRECOX. 

Genuine precocious menstruation in early childhood is of very 
rare occurrence. If it does occur, it is usually associated with development. 
general bodily and mental overdevelopment. The diagnosis of 
menstruatio prsecox should notbe made until vao-inal bleeding^ Mistakes in 

_ J^ . _ *=> *=> diagnosis. 

from local injury, from papillomatous growths, prolapse of the 
urethral mucous membrane, and hemophilia, has been excluded. 
Precocious menstruation, being free from serious consequences 
to the general health, calls for no therapeutic measures, except 
perfect rest during menstruation. 



CHAPTER XII. 
Diseases of the Blood and Ductless Glands. 



Usually 



The grouping together of the affections of the blood and 
ductless glands is intended to emphasize their correlation. They 
are of very common occurrence in children, especially in infancy 
and in those approaching puberty. At these periods of life, 
owing to the rapid bodily development, the blood-forming organs 
are taxed to their greatest capacity, and, hence, are very apt to 
suffer on slight provocation. The anemias of children are usually 
secondary, secondary in nature, only exceptionally primary. With the 
present inadequate state of our knowledge, however, no sharp 
line of demarcation can be drawn between the various types of 
blood disease. Only too often do we find the clinical and histo- 
logic aspects of simple secondary anemia merging into that of 
splenic anemia, and that of the latter disease into the one of 
leukemia. The same is true of lymphatic leukemia, chloroma, 
and lymphosarcoma. For the reasons just stated, therefore, no 
attempt will here be made to offer an ironclad classification of 
the diseases in question. 

In studying blood disease it is well to bear in mind that the 
constituents of the normal blood vary within more or less wide 
limits, and that slight ailments are prone to produce marked 
disproportion between the number of red and white blood- 
corpuscles. 

At birth the number of red cells is about 6,000,000, and of 
Normal white cclls, between 20,000 to 30,000 per cubic millimeter. The 
hemoglobin is very high (about 110 per cent.) and the specific 
gravity 1066. After the second week the red cells fall to 
5,000,000, and the white cells to about 15,000, the hemoglobin to 
100 per cent., and the specific gravity to 1050. The red cells are 
fewer in number in the female than in the male. The percentage 
of the different leucocytes in infants presents the following 
variations : Polymorphonuclear neutrophiles, 28 to 50 ; poly- 
morphonuclear eosinophils, ^ to 10; lymphocytes, 50 to 70, and 
large mononuclears, 6 to 14. The adult proportion is usually 
(470) 



blood. 



CHLOROSIS. 471 

reached by the time the child is six years old. Then the number 
of leucocytes falls to about 10,000, presenting the following 
percentage : Neutrophiles, 65 to 75 ; eosinophiles, ^ to 4 ; lympho- 
cytes, 20 to 30, and mononuclears, 1 to 4. Normally coagulation 
of the blood usually occurs within from two to five minutes. 

ANEMIA SIMPLEX, CHLOROSIS 
(Green Sickness). 

Both of these conditions present identical pathologic changes 
in the blood — reduction in the number of red cells, decrease of Reduction of 

red cgIIs 

hemoglobin, without marked changes in the cells themselves — and 
but differ somewhat in the etiology and course. Thus, while 
chlorosis is ordinarily encountered in girls at puberty, and almost 
invariably ends in recovery without any grave alterations in the 
general health, anemia is a disease of younger children, and if 
occurring in infants very frequently forms the forerunner of 
that type of blood disease which is generally described as pseu- 
doleukemia infantum (q.v.). 

Anemia as well as chlorosis is manifested by pallor of the Paiior. 
face (green complexion) and mucous membranes, headache, 
dyspeptic symptoms, undue fatigue after slight exertion, attacks 
of palpitation of the heart and of dyspnea, general debility and Palpitation 
excessive irritability of the nerve system. Auscultation often ^ 
reveals hemic murmurs along the large veins of the neck and at 
the base of the heart, which differ from organic murmurs by 
their inconstancy and frequent change in their intensity and 
location. 

In addition to the aforementioned manifestations chlorosis in 
mature girls is very prone to give rise to amenorrhea, dysmenor- 
rhea, and less frequently to menorrhagia with consecutive aggra- 
vation of the original condition; severe chlorosis is apt to be ^atkms" 
complicated by venous thrombosis, especially in the lower 
extremities and the brain sinuses, and occasionally to secondary 
gangrene and embolism. Of course, such occurrences are very 
exceptional. The very great majority of cases of chlorosis, as 
already stated, improve rapidly and fully, although relapses are 
not uncommon. 

The management of anemia and chlorosis to a great extent 
varies with the numerous etiologic factors. The general health Nutritious 
should be improved by suitable, nutritious diet, plenty of out- '^^^^• 
door air, cold shower baths with gentle massage, ample sleep, and ^^^^^ ^^^- 



Iron and 
arsenic. 



472 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

Rest, avoidance of undue excitement and physical and mental over- 
exertion. Dyspepsia, habitual constipation, diarrhea, loss of 
blood (epistaxis, etc.), hereditary syphilis, malaria, tuberculosis, 
heart and kidney affections, and all other diseases as are apt to 
undermine the system should receive prompt and continuous 
attention. Where circulatory disturbances are very pronounced, 
rest in bed is indispensable. Medicinally iron and arsenic are 
the remedies of choice. The following combination acts splen- 
didly:— 

^ Liquoris arsenici chloridi 3j 4 

Tincturse ferri chloridi 3iij 12 

Syrupi aurantii q. s. ad Biij 90 

M. Sig. : One teaspoonful every three hours for a child 6 years old. 

In older children, to avoid destruction of the teeth, the iron 
and arsenic, without the syrup, may be prescribed with instruc- 
tions to be taken in capsule form, each dose being prepared 
before taking it in accordance with the directions given on 
page 115. 

Digestives and tonics (cod-liver oil) will be found to act as 
useful adjuvants. Change of air, preferably to mountainous 
regions. 

PSEUDOLEUKEMIA LYMPHATICA 
(Hodgkin's Disease, Adenie, Lymphadenoma). 

This disease is characterized by multiple hyperplasia of the 
Multiple lymph glands with progressive anemia. The cervical glands are 
adeStis" most commonly and severely attacked, but the lymphoid tissue 
of the entire body is more or less involved. It closely resembles 
tuberculous adenitis, except that it is much less common than 
tuberculosis and that in the latter condition the glands show a 
greater tendency to caseation and suppuration. In doubtful 
cases the tuberculin test may prove decisive in the diagnosis. 

The changes in the blood and the clinical manifestations are 

identical with those observed in anemia. Occasionally there are 

local pressure-symptoms, such as pain, edema, cough and dyspnea. 

Under suitable treatment, which is essentially the same as in 

In simple simple anemia, recovery or, at least, arrest of the disease is pos- 



anemia. 



sible. Intractable cases often terminate in leukemia. 



PSEUDOLEUKEMIA. 



473 



PSEUDOLEUKEMIA INFANTUM SPLENICA 
(Von Jaksch or Splenic Anemia). 

In contrast to genuine leukemia, pseudoleukemia splenica is 
of quite frequent occurrence, slow in its course and favorable in siow 

^ ^ ^ course 

its outcome. The etiology of this affection is obscure. As a 




Fig. 144. — Pseudoleukemia Infantum Splenica. Note position 
of enlarged spleen. (Sheffield.) 



rule, it is observed in connection with pronounced forms of mal- 
nutrition, especially rachitis. 

The chief alterations in the blood are reduction of red cells 
and hemoglobin, the presence of many nucleated red corpuscles, 
and an increase in the number of leucocytes, mostly of the mono- increased 
nuclear type. This blood picture essentially corresponds to that leukocytosis. 
of ordinary secondary anemia. In pseudoleukemia infantum. 



474 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

^^^Te^n^ however, there is marked enlargement of the spleen and occasion- 
ally also of the liver and lymphatic glands. 

The general symptoms differ but little from those observed in 
severe anemia. The same applies to the treatment. The syrup 
of the iodid of iron with the syrup of the hypophosphites seem 
to exert a specific action in the majority of cases. 




Fig. 145. — Same case as Fig. 144 after three months' tonic treat- 
ment. Note reduction in size of spleen. (Sheffield.) 

LEUKEMIA 
(Leucocythemia). 

As the term indicates, leukemia is characterized principally 

High leuco- . 

cytosis with by an abnormal increase in the number- of leucocytes (sometimes 

unusual -^ 

bi ^y^^ls^ reaching as high as a million), and by the presence of unusual 
types of these cells, i.e., Markzellen (myelocytes), Mastzellen 
(nutritive cells), and giant basophiles. From a pathologic point 



Splenic. 



PERNICIOUS ANEMIA. 475 

of view it is customary to distinguish two forms of leukemia: Lymphatic. 
1. Lymphatic leukemia, in which the lymphatic glands are chiefly 
involved (hyperplasia), and 2. Splenomedullary or myelogenic 
form, in which the spleen (greatly increased in size) and the 
bone marrow (hyperplasia) are the principal seats of the lesion. 
Mixed forms also are encountered. The principal difference JJrms. 
between the two forms of leukemia are the preponderance of 
lymphocytes in lymphatic and myelocytes in splenic leukemia. 
The red cells and hemoglobin are reduced in both varieties. 

The clinical manifestations are essentially identical with those 
of pernicious anemia, plus enlargement of the lymphatic glands, 



Fig. 146. — Acute Leukemia. This picture is made from two 
different, rapidly fatal, clinically similar cases. The upper portion 
is stained with Ehrlich's stain with eosin-hematoxylin ; the lower 
portion is stained with the Plehn-Chenzinsky's stain. {Lenharts 
and Brooks.) 

or spleen and liver. The disease may run a very acute course 
(acute leukemia), and end fatally within a week or two, or prognosis. 
proceed a slower course (chronic leukemia), and lead to a fatal 
issue after a few months. 

As the nature of leukemia is entirely obscure, little else can 
be done but treat it symptomatically. 

PERNICIOUS ANEMIA. 

This form of anemia is characterized by great diminution in ^^.^^^ 
the number of red cells (2,000,000 to 1,000,000 per centimeter) ; Jf^^'ed'ce'iis 
reduction in the total quantity of hemoglobin with a comparative 



476 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

increase of the hemoglobin in the red cells; increase in the size 

Megaiobiasts. of the red cells with predominance of megaloblasts ; loss of 

cohesive quality of the red cells (their failure to form rouleaux), 

and, finally, absence of distinct change (or slight reduction) in the 

Normal number of the leucocytes. 

This blood affection is very rarely met in children. As in 
adults, it may occur secondarily to protracted simple anemia or in 
Intestinal couscqucnce of abstraction of blood by intestinal parasites, e.g., 
bothriocephalus latus; uncinaria {q.v.). 



leucocytosis. 



parasites. 




Fig. 147. — Progressive Pernicious Anemia. The case ended 
fatally in six weeks ; cause unknown ; possibly in connection with 
typhoid fever. Ehrlich's triacid stain. Zeiss ocular 1, oil immer- 
sion M^, a, normal erythrocytes; h. megalocytes ; c, microc5rtes; 
d, marked poikilocytosis ; e, megaloblast ; /, polynuclear neutro- 
philic leucocyte. {Lenhartz and Brooks.) 



In the beginning the symptoms resemble those of severe 

simple anemia {q.v.), but at a later stage of the disease the con- 

Hemor- dition IS greatly aggravated by supervening hemorrhages from the 

mucous membranes, cutaneous ecchymoses and general dropsy. 

In such cases death invariably occurs within a few months. 

Post-mortem examination usually reveals fatty degeneration 
of the internal organs. 

The treatment is the same as in severe anemia (see page 472). 
Besides, removal of intestinal parasites, if present. 



H.EMORRHCEA CONGENITA. 477 

H^MORRHCEA CONGENITA 
(Hemophilia). 

Hemophilia is an inherited, congenital tendency to post- 
traumatic or spontaneous, profuse, often uncontrollable hemor- 
rhage. It affects boys much more frequently than girls and 
shows a predilection for those of the Hebrew race. The disease 
becomes less marked with advancing age. 

The nature of the disease is still obscure. It is reasonable 
to suppose, however, that some toxic hemolytic agent transmitted 
through the spermatozoa or the maternal blood exerts its dele- 
terious influence upon the embryo in its very earliest develop- 
ment, leading to permeability and friability of the blood-vessel 
walls and lessened coagulability of the blood — these being the only Lessened 
characteristic changes met with in hemophilia with a certain ofThe^^^^^^^ 
degree of regularity. biood. 

While, as previously alluded to, the hemorrhage may start 
spontaneously, in the great majority of cases it follows some 
trivial injury. A scratch or the prick of a pin or slight abrasion spontaneous 
of the body surface, vaccination, snipping of the frenum, cir- or^fter^^^^ 
cumcision, extraction of a tooth, opening of abscesses, etc., are injurU 
followed by severe often uncontrollable hemorrhage. Any undue 
exertion of a muscle or a group of muscles {e.g., jumping off" a 
chair, sudden twisting of an arm), a bump or a blow, etc., often 
gives rise to a profuse extravasation of blood into the skin or 
joints. Forcible blowing of the nose may be followed by an 
exsanguinating nosebleed, and in a case under our observation 
sneezing produced an enormous hemorrhage from the nose and 
ear (rupture of the drum!) which nearly ended fatally. In girls 
hemorrhages may occur from the vagina (often mistaken for 
menstruatio prsecox) long before the age of puberty; and with 
establishment of menstrual function, the bleeding may be so pro- 
fuse as to leave the patient monthly in a state of collapse. Hema- 
temesis, hemorrhage from the bowels and hematuria are less 
common, and bleeding into the serous cavities (peritoneal, pleural 
and pericardial) and the brain are still less frequent. Hemophilia 
in the newly born may be manifested during or immediately after 
birth by severe hemorrhages occurring from abrasions and con- 
tusions sustained during delivery, or after cutting the umbilical 
cord. These hemorrhages are not to be mistaken for hsemorrhcea mistaken^ 
neonatorum complicating sepsis (see page 181) or the so-called n°eona?orum. 
transitory hemophilia which is manifested by idiopathic umbilical 



478 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

hemorrhage (see page 174) or fearful, sometimes fatal bleeding 
following ritual circumcision. In this form of hemophilia the 
iiem??rhagZ tendency to hemorrhage is greatest between the seventh and 
fourteenth days of life, gradually lessening in intensity until the 
infant reaches the age of two or three months, when it dis- 
appears entirely. The differential points of diagnosis between 
hsemorrhoea congenita and hsemorrhoea acquisita will be spoken of 
in the discussion of the latter aft'ection (see page 480). 

Little can be expected from treatment, except in mild forms 

pEirtiiil 

bleeders, of hemophilia (''partial bleeders"). SteriHzed, hquid gelatin, 
(10 per cent.), administered twice daily, for months at a time, per 
mouth, rectum or hypodermatically has proved very serviceable, 
especially in partial bleeders. Calcium chloride, in from 2-grain 
to 5-grain doses, twice daily is useful. Thyroid gland substance, 
in small doses, continued for weeks at a time, is deserving of trial. 
To arrest the hemorrhage we may resort to the actual cautery, 
compression, suprarenal extract, perchlorid of iron, etc. Recently 
fresh rabbit-serum and horse-serum have been highly recom- 
mended. 

We should guard against injuries and operative interference 
(gelatin feeding before operation is helpful) of all kinds. 

Bleeders, especially females, should not marry. 



Prophylaxis. 



H^MORRHCEA ACQUISITA 

(Purpura Simplex. Purpura Haemorrhagica s. Morbus 

Maculosus, Purpura Fulminans). 

Purpura is an acquired affection of the blood or its vessels 
characterized by hemorrhages into the skin, mucous membranes 
and other tissues and more or less marked constitutional dis- 
turbance. 
^'^^mtcrJbic ^^^^ ctiology of the disease is still obscure, but is probably a 
origin, spccilic iiiicro-organism which invades the blood. 

Purpura is most frequently observed in children (male and 

female) over five years of age, and more rarely in younger ones. 

Free from Ji occurs either as a primary affection or in connection with acute 

nemorrnagic ^ -^ 

tendency at infectious discases, such as scarlatina, measles, typhoid, etc., and 

Dirtn or ^ _ ... 

thereafter^ shows a predilection for poorly nourished, anemic and rachitic 
children living in dark, damp dwellings, with bad hygienic 
surroundings. 

Consonant with the degree of severity of the aft'ection, it is 
customary to distinguish the following forms of purpura : — 



H.^MORRHCEA ACQUISITA. 479 

1. Purpura Simplex. — The hemorrhage is confined to the 
skin only, and appears as pinhead- to lentil-sized spots at first 
upon the lower extremities, but later also on the other portions 

of the body. Aside from occasional prodromata consisting of hemorrhage. 
gastroenteric disturbance of brief duration, it is free from con- 
stitutional manifestations. Tlie majority of these cases pursue 
a favorable course. The petechise either subside entirely within 
from one WTek to one month, or return at shorter or longer 
intervals, in which latter event transition into a severer type of 
the disease is not uncommon. 

2. Purpura s. Peliosis Rheumatica. (See page 424.) 

3. Purpura Haemorrhagica (Morbus Maculosus Werlhofii). Hemorrhage 
— This form' of purpura is manifested by hemorrhages in the and mucous 

, . 11-1 1 T • • 1 membranes. 

skm as well as m the mucous membranes. Its onset is either 
sudden or preceded by slight prodromata or purpura simplex. 
The skin petechi?e may vary in size from a lentil to the palm of 
a hand, and do not disappear on pressure. They usually spread 
rapidly over the entire body. The hemorrhages into the mucous 
membranes are rarely very profuse. As a rule, there are only 
ecchymoses upon the mucous membranes of the nose, gums, and 
pharynx, but in severe cases the hemorrhagic tendency may 
extend to almost every structure and organ of the body, so that 
the patient bleeds from the nose, mouth, ears, retina and choroid, 
throat, lungs, stomach, bowels, kidneys, genitalia, etc., and some- 
times even into the brain and cord. Under these conditions there 
are well-marked constitutional symptoms (prostration, headache 
and articular pain, cerebral symptoms as a result of the anemia 
or meningeal hemorrhage, colic and tenesmus, etc.), but in mild 
cases the patient may appear perfectly well. The course of the 
disease, therefore, varies with the seat and amount of the bleed- 
ing. An attack of purpura haemorrhagica of medium severity 
usually lasts from ten to fourteen days. After about a week the 
cutaneous ecchymoses begin to change from the original red to 
bluish, yellow, greenish and brown, and disappear entirely within 
another week. The hemorrhages from the mucous membranes 
and viscera also gradually cease, the general condition of the 
patient improves, and recovery ensues, apparently without any 
serious consequences. On the other hand, in a great many cases, 
not only may the course of the first attack be protracted for 
weeks and months by frequent recurrences of the bleeding, and Recurrences. 
lead to profound anemia and death, but a tendency to relapses is 



480 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

not rarely established, which may manifest itself on slight 
provocation. 

4. Purpura Fulminans (Henoch). — This type of purpura is 
essentially identical with the former variety, except that its course 
course, is extremely rapid and violent, with severe constitutional symp- 
toms, such as chills, vomiting, hyperpyrexia, cerebral symptoms, 
and collapse. It is invariably fatal, death taking place with symp- 
toms of cardiac paralysis, within from one to four days. Post- 
mortem examination is negative. 

Purpura may occasionally be complicated by gangrene of the 
skin, subcutaneous tissue or mucous membranes, rendering the 
prognosis very much worse. 

In the early stage of the disease hsemorrhoea acquisita may be 
^dfagnosis! niistaken for hsemorrhoea congenita, infantile scurvy, and exan- 
themata (scarlatina, morbilli diphtheria, variola, typhoid, etc.) 
with hemorrhagic symptoms. 

Hemophilia presents a history of an hereditary tendency, 
most frequently follows some local injury, and if it occurs spon- 
taneously almost never involves several portions of the body 
simultaneously. 

hifantile scurvy is an affection principally of early infancy 
and associated with malnutrition. The hemorrhage is also deep- 
seated ( subperiosteal ) . 

Exanthemata have pathognomonic symptoms of their own 
which are wanting in purpura. The concurrence of the former 
with the latter, however, should not be lost sight of. 

Purpura associated with sepsis can readily be recognized by 
the septic symptoms. 

The treatment of purpura is very unsatisfactory. Mild cases 
usually recover spontaneously, and grave ones may go from bad 
to worse even under the best mode of treatment. Absolute rest 
in bed, nutritious diet, plenty of fresh air, iron and arsenic, and 
the administration of fresh fruit-juice will enhance the arrest of 
milder forms of the disease. 

The hemorrhagic tendency may in some cases be checked by 
means of suprarenal gland extract, aromatic sulphuric acid, 
calcium chloride, and spirits of turpentine. Local hemorrhage 
should be treated in accordance with the rules laid down for the 
management of bleeding from other causes (compression, ice- 
bags, styptics, etc). After cessation of the bleeding tonics are 
useful. Stimulants, in collapse. 



Treatment. 



■ DISEASES OF THE SPLEEX. 481 

MORBUS ADDISONII 
(Bronzed Skin). 

The pathogenesis of this affection is as yet awaiting correct 
interpretation. While in the majority of cases post-mortem 

Caseation 

examination reveals disease of the suprarenals (caseation or and caicifi- 
calcification), cases of Addison's disease are also on record which suprarenals. 
failed to show distinct pathologic changes in these glands. The 
disease usually attacks children over ten years of age and excep- 
tionally younger ones. It is manifested by progressive emacia- 
tion, dyspepsia, uncontrollable diarrhea, anemia, and bronze-like 
discoloration of the skin. The discoloration begins at the breast 
nipples, axillary regions, hands and face, and gradually aff'ects 
the entire body. The patients succumb within from a few months 
or years to exhaustion and paralysis of the heart. 

Hematinics, roborants, and, possibly, suprarenal, parathyroid 
and pituitary extracts are deserving of trial. 



DISEASES OF THE SPLEEN. 

Spleen aft'ections are manifested principally by enlargement of 
the organ — demonstrable by palpation and percussion. 

MOVABLE SPLEEN 
(Wandering Spleen, Lien Mobilis). 

This condition is important chiefly from a diagnostic point of 
view% as it is apt to be mistaken for splenic enlargement. It 
dift"ers from the latter by the absence of constitutional symptoms 
and by the softer consistence of the spleen. It is usually asso- 
ciated with general atony of the entire musculature, especially of muscular 



the abdominal wall, and in older children not rarely with sinking 
of the intestines, floating liver and kidneys. Subjective symp- 
toms may be absent. Older children may complain of a feeling 
of weight or pain in the left side, colic, and nausea. 

Mild cases frequently obtain permanent relief from the use 
of an abdominal binder and general tonic treatment (massage, 
cod-liver oil, arsenic). In very pronounced cases splenectomy is 
indicated. 

ACUTE SPLENITIS 
(Splenic Congestion). 

x\n acute splenic enlargement may be caused by malaria, 
typhoid, recurrent fever and miliary tuberculosis ; more rarely by 

31 



atony. 



482 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

influenza, rotheln, scarlet fever, tuberculous meningitis, mumps, 
Usually erysipelas and angina. Very rapid and intense enlargement of 
secon ary. ^^^ spleen may occasionally be followed by rupture of the spleen, 
hemorrhage in the abdominal cavity and death. 

In the majority of instances the splenitis subsides sponta- 
neously with the underlying cause. If the disease is due to 
direct infection by pyogenic micro-organisms, trauma (with open 
wound) or metastasis, it may end in suppuration (splenic 
abscess). Occasionally the inflammation extends to the sur- 
rounding tissues, especially to the capsule of the organ, peri- 
splenitis, and gives rise to inflammatory adhesions to neighboring 
structures (diaphragm, colon or fundus ventriculi). 

CHRONIC INFLAMMATION OF THE SPLEEN 
(Chronic Hypertrophy, Splenomegaly). 

Occasionally chronic enlargement of the spleen is the result 
of acute splenitis. Most frequently, however, it develops insid- 
iously in connection with chronic malaria, syphilis, tuberculosis, 
rachitis, leukemia, pseudoleukemia and amyloid degeneration. 
The symptoms vary with the original cause and the degree of 
sympfoms^ pressure exerted by the spleen upon the neighboring structures. 
No attempt will therefore be made to go into a detailed descrip- 
tion of the symptomatology. Mention may here be made of the 
Idiopathic f^ct that in the so-called ''idiopathic" splenomegaly the patient 
form, j^^^y appear entirely free from constitutional manifestations. 

The treatment is symptomatic. If the spleen alone is involved 
and gives rise to grave pressure symptoms, splenectomy may be 
resorted to. 

BANTI'S DISEASE. 

This disease is not infrequently observed in children. It is 
spieno- characterized by splenomegaly, anemia, ascites, cirrhosis of the 
AscSS' liver, and hemorrhages. Early splenectomy is said to cure the 

affection. The diagnosis can be made only by exclusion of 

similar spleen and liver diseases. 



DISEASES OF THE THYMUS GLAND. 

The thymus gland consists of two lateral lobes coming in close 
contact along the middle line. It is situated in the anterior por- 
tion of the neck and superior mediastinum, extending from the 



DISEASES OF THE THYMUS GLAXD. 



483 



lower border of the thyroid gland to the upper border of the 
fourth rib. The thymus varies greatly in size and weight. It is 
about IV-y inches in length, 1^4 inches in width (at its lower 
portion), and a quarter of an inch in thickness. It attains its 
greatest development (weighing 34 ounce) between the first and 
second years, and undergoes rapid degeneration soon after 
puberty, so that, at the age of twenty, it is a mere vestige of 
lymphoid tissue and fat. In children under six years of age, light 
percussion over the superior mediastinum reveals a triangular 



Normal 
anatomy. 




II 




Fig. 148. — Large Thymus ( skiagram j. 



field of dullness, its base being on a line w^th the sternoclavicular Triangular 
articulations, and its apex the second rib. It is well to remember, dullness. 
however, that similar dullness is obtained in enlarged bronchial 
glands. 

Like other glands of the body the thymus gland is subject to Thymitis. 
acute and chronic inflammation (thymitis) w^ith consecutive 
hyperplasia, or premature atrophy; tuberculosis; syphilis, and 
neoplasms. 

Acute thymitis occurs usually secondarily to systemic pyemic 
processes or by extension of the inflammation from the adjacent 
structures. The inflammation is very prone to lead to suppuration 
of the gland. 

Hypertrophy of the thymus is sometimes inflammatory in Hypertrophy. 



Syphilis. 



484 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

nature and sometimes of obscure origin. When the enlargement 

of the gland is pronounced, the diagnosis can frequently be made 

Dullness; by an increased area of thymus-dullness over the sternum, by an 

swelling. ^j.^,]^g(^ elastic swelling above the incisura sterni, and by its asso- 
ciation with enlargement of the lymph glands in the lateral lower 
region of the neck. The X-rays are often very helpful in the 
diagnosis. In the majority of instances thymus hypertrophy 
gives rise to disturbances of the circulatory and respiratory 
("asthma thymicum," "inspiratory stridor of sucklings") organs, 

Pressure as a result of pressure upon neighboring blood-vessels, nerves, 

symptoms. 1^1 

and trachea. 
Tuberculosis. Tubcrculosis of the thymus gland, as a rule, is not discovered 

until post mortem, and hence is of no clinical importance. To 
a great extent the same is true of syphilis of the thymus, which, 
by the way, is of very rare occurrence. Both of these pathologic 
processes usually lead to atrophy. 
Sarcoma. Sarcoma is the most common new growth of the thymus 

gland. The symptoms and diagnosis are essentially identical with 
those of hyperplasia, already referred to. 

As the affections of the thymus at best escape detection until a 
late stage, little can be accomplished in the way of treatment. 
Where syphilis is suspected the iodids will prove efficient and in 
cases of neoplasm an attempt may be made to extirpate it. Acute 
inflammatory symptoms should be relieved by antiphlogistic 
measures (ice, cupping, and the like). 

STATUS LYMPHATICUS 
(Thymus Death). 

Sudden In a certain number of apparently healthy children sudden 

*inlr death occurs after some trivial cause, such as shock following 
slight trauma, or operation, injection of serum, etc., inhalation of 
a minute quantity of an anesthetic and the like. Post-mortem 
examination reveals no definite lesion in any organ to account for 
the sudden death, except general enlargement of the lymphoid 
tissue of the body (adenoids and tonsils, the follicles of the intes- 
tinal walls, the peripheral glands, etc.) and especially of the 
thymus gland. This pathologic condition is being generally 
described as "status lymphaticus." The pathogenesis of this 
anomaly is still shrouded in mystery. The view previously held 
that such deaths were the immediate result of compression of the 
neighboring vital structures by an enlarged thymus ("thymus 



trivial 
cause. 



operating. 



DISEASES OF THE THYROID GLAND. 48-5 

death") has been found devoid of indisputable pathologic or 
clinical foundation. 

Whatever the etiologic basis, however, the mere fact that sud- 
den death may follow any of the aforementioned seemingly harm- caution in 
less therapeutic measures should serve as a warning against their 
employment in children in whom status lymphaticus is suspected. 
Children suffering from scrofula, rachitis, spasmus glottidis, and 
the like, belong to this category. 



DISEASES OF THE THYROID GLAND. 

The normal thyroid gland is somewhat larger in children, 1^0^.2^31 
especially girls, than in adults. It consists of three lobes, one ti^yroid. 
middle small lobe (inconstant) and two larger lateral lobes. The 
latter are connected by an isthmus. The lateral lobes are situated 
on each side of the trachea along the second and third tracheal 
rings ; the middle lobe lies in front of the thyroid cartilage and 
ascends upward in the direction of the middle of the hyoid bone. 
As the gland is thin and often lies deeply imbedded into the 
neck, it is very rarely possible to determine the size of a normal 
thyroid by palpation. 

THYROIDITIS 

(Strumitis). 

Primary inflammation of the thyroid gland is usually of 
traumatic origin (direct violence, or injury during delivery). It 
is of very rare occurrence. More frequently we meet with 
secondary thyroiditis, as a rule, in connection with acute exan- 
thematous diseases and occasionally with parotitis, malaria, and 
articular rheumatism. 

The symptomatology consists of swelling of the gland, pain s^,eiiing, 
on pressure as well as on moving the neck, and in some cases red- preSsure*^ 
ness, fluctuation and suppuration, and more or less marked pres- ^y^^ptoms. 
sure symptoms. 

The inflammation usually disappears under local application 
of cold. Should an abscess form, it demands immediate evacua- 
tion of the pus and drainage. 

Severe protracted thyroiditis not rarely leads to atrophy of 
the gland. 



486 DISEASES OF BLOOD AND DUCTLESS GLANDS. 



Hyperplasia. 

Cystic 

degeneration. 



GOITER 

(Struma). 

As in adults, the thyroid gland of children is subject to hyper- 
plasia and cystic degeneration. In countries where goiter is 
endemic it is not rarely observed in very young infants, and is 
probably of antenatal origin. On the other hand sporadic goiter, 
as a rule, develops at the period of puberty, particularly in girls. 




Fig. 149.— Goiter (11 years old). (Sheffield.) 



Pressure 
symptoms. 



Small goiters may remain free from any manifestations, 
except the local swelling in the anterior portion of the neck, while 
goiters large enough to exert pressure upon the adjacent struc- 
tures may prove a menace to life by compression of the trachea, 
and the large blood-vessels and nerves which abound in the neck. 
The pressure symptoms ordinarily consist of headache, dizziness, 
aphonia, dyspnea and paroxysmal cough. This grave symptom- 
complex, however, is of unusual occurrence. 

On the whole, the prognosis is favorable. The great majority 
of cases of goiter yield promptly to internal administration of 



DISEASES OF THE THYROID GLAND. 



4<S7 



small doses of iodin, with or without thyroid or parathyroid gland 
substance, and external use of iodin ointment. Large goiters 
causing marked pressure symptoms call for their extirpation. 

In countries where goiter is endemic its development to a 
great extent may be prevented by change of residence, by boiling Distilled 
the drinking water, and by drinking large quantities of distilled prophylactic. 
water. 

In infants goiter may be mistaken for a large hygroma 




Fig. 150. — Cystic Goiter. Within the last two years patient 
(13 years old) has been gradually becoming feeble-minded. 
(Sheffield.) 



cysticum coli cono^enitum or other cysts of the neck, and in ^.^ 

-^ _ *=" _ _ -^ ' Differentia- 

older children for exophthalmic goiter. Cysts of the neck are tion from 

'■ ° •' ^ cysts in the 

characterized by marked fluctuation and rapid development ; i^eck. 
and usually arise from the submaxillary region. 

Exophthalmic Goiter (Basedow^'s or Graves's Disease) is 
characterized, in addition to the goiter, by tachycardia, muscular ^^^^ card a 
tremor, exophthalmos, general ill health, vasomotor disturbances ^^^^^_ ^°*^ 
(flushes of the skin alternating with pallor), and pigmentation of thaimos. 
the skin. 



488 DISEASES OE BLOOD AND DUCTLESS GLANDS. 

CRETINISM 

(Endemic or Goitrous Cretinism, Sporadic Cretinism or 

Myxidiocy). 

Arrest of Cretinism is due to partial or total arrest of the secretion of 

thyroid . , 

secretion, the thyroid gland, in consequence of congenital or acquired 




Fig. 151. — Congenital Cretinism. Child 6 months old; showed 
typical symptoms soon after birth. (Sheffield.) 

(extirpation) absence, atrophy (from strumitis, syphilis, tuber- 
culosis, or neoplasms), or goitrous degeneration of the gland. 
Endemic cretinism occurs in children living in countries where 
Endemic. gQJj-gj- jg endemic, or in descendants of people coming from these 
regions, and is very frequently associated with goiter. On the 
other hand, sporadic cretinism is observed in children coming 

Sporadic. ' ^ ... 

from other parts of the world. The term ''myxidiocy" is usually 



DISEASES OF THE THYROID GLAND. 



489 



reserved for the pronounced forms of cretinism which are asso- 
ciated with marked pseudoHpomatosis. 

The great majority of cases of cretinism in children are of usually 
antenatal origin, although the pathognomonic manifestations with 
few exceptions (see Fig. 151) do not appear until the child is 
over one year of age. At about this time it is usually noticed 



congenital. 




Fig. 152. — Sporadic Cretinism in a Girl 8 Years Old. She 
measured 33 inches in height. (Sheffield.) 

that the infant's bodily development is arrested, and its intelli- 
gence, instead of rapidly progressing, grows perceptibly backward. 
The f ontanelles remain open ; the head is large, flat and plump piiysicai and 
and set upon a thick and short neck. The forehead is low and development. 
the root of the nose is broad. The face is weak and senile ; the 
eyelids, lips and tongue are thick and the latter slightly or 
markedly protrudes from the half-open mouth. The teeth are 
slow in coming and rapid in decaying. The abdomen is greatly 



490 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

distended, often presenting an umbilical hernia. The extremities 
are more or less deformed and the articulations thickened. The 
hands and feet are short, broad and thick. Cretins slowly learn 
to walk, but their gait is dragging and awkward, with a tendency 
to fall forward. If left untreated typical cretins rarely attain 

Feeble- 3 feet in height. Ordinarily cretins of ten or twelve years of 
up to age appear but two years old in stature, and still younger in their 

idiocy, mental development. The intelligence of the cretin is invariably 




Fig. 153. — Same case as Fig. 152 at the age of one year. 
Apparently perfectly normal. (Sheffield.) 



Half-cretin. 



below par ; it varies, however, greatly with the functionating 
capacity of the thyroid gland, and the period at which the morbid 
process makes itself felt. Thus, some cretins (''half-cretins") 
possess a fair measure of intelligence, appreciate their surround- 
ings and are able to acquire a vocabulary ample to make their 
wants understood or even to hold an intelligent conversation; 
others are totally idiotic and grow more stupid with advance in 
years. The special senses suffer greatly. Taste and smell are 
obtuse ; hearing is defective and not rarely associated with mutism. 
The voice is husky. In early infancy, before the degree of 
intelligence is determinable, the diagnosis of cretinism can fre- 



DISEASES OE THE THYROID GLAND. 



491 



quently be made by the dryness and waxy color of the skin ; the 
profound anemia; the sparseness and brittleness of the hair; the Pseudo 
subnormal temperature and the presence of so-called ''fatty 
tumors" in the clavicular regions. 

As the child grows older it is noticed also that the genitalia 



lipomatosis 




Fig. 154. — Sporadic Cretinism. Same case as Fig. 152, after 
two months' treatment with thyroid. Xote complete transforma- 
tion of features, etc. She gained 2 inches in height. {Sheffield.) 



and their functions remain in a primitive state. Typical cretins, 
fortunately, have no power of perpetuating their monstrous 
kind. 

Up to the discovery of the underlying pathologic basis of the Hopeless 
disease, cretins used to go on from bad to worse until finally J^y^oid 
relicA'cd of their miserable existence by death, at an age of from 



492 DISEASES OF BLOOD AND DUCTLESS GLANDS. 

thirty to forty or earlier in consequence of intercurrent diseases. 
Specific Nowadays, however, a great deal can be done to ameliorate their 
thyroid! Condition by the administration of thyroid gland. Partial cretins 
particularly can now be improved sufficiently as to enable them 
to pursue some occupation and to provide for their maintenance. 
The results obtained from thyroid medication are often miracu- 
lous. After exhibition of thyroid but for a short time — some- 
times only a few weeks (see Fig. 154) — the cretin is frequently 
transformed from an uncouth, apathetic and clumsy little creature 
into a lusty, gracile and growing human being. The blurred 
facial features gain youthful expression, the lusterless and 
withered hair takes on new life, the stunted stature approaches 
normal proportions and the brutal stupidity slowly gives way to 
human intelligence. The sooner the treatment is begun and the 
longer it is persisted in the more certain are the favorable results. 
At best, however, a cretin always remains childish for life — 
mentally as well as physically. 

The thyroid gland may be administered in the form of extract 
adminis- (1 grain for every year of the child's age, twice a day), the fresh 
thyroid gland, or any of the numerous thyroid preparations on 
the market. The effect of thyroid is often enhanced by combin- 
ing it with parathyroid. (See page 121.) 

Endemic cretinism may frequently be prevented by treating 
Prophylaxis, the pregnant mother with thyroid-gland extract. 

For the differential diagnosis between cretinism and other 

Differential r • i- i • r ut ^• 

diagnosis, forms of idiocy, the reader is referred to the chapter on idiocy 
and the Allied Mental Deficiencies," page 570. Mention will 
here be made of the fact that in doubtful cases the diagnosis can 
often be decided by the experimental administration of thyroid 
gland. 

The advisabihty (and success) of transplanting the thyroid 
gland from a sheep is still subject to controversy. 



CHAPTER XIII. 
Disturbances of Metabolism. 



Intestinal 

autoi 

tion. 



Apparently 
normal at 
birth. 



MARASMUS; ATHREPSIA; INFANTILE 
ATROPHY (PEDATROPHY). 

The nature of this appalling infantile wasting is still shrouded 
in mystery. It is apparently only a functional disorder, a form 
of intestinal autointoxication, arising from non-assimilation of autointoxica- 
the food consumed, since the post-mortem lesions (atrophic 
patches in some portions of the intestinal tract') are not uniform 
and rapidly disappear when the atrophic infant is put on a suit- 
able diet, Avhich may vary from an ideal breast milk to some 
proprietary artificial food ( !). In this group, of course, are not 
inchided the cases of marasmus accompanying tuberculosis, 
syphilis and the like. 

Whatever the pathology and cause, the symptomatology is 
very pathognomonic. The apparently normally born infant, after 
thriving fairly well on the milk-mixture it has been receiving. 
begins to show signs of ill health and rapidly loses in weight. 
The food disagrees ; it is vomited or regurgitated. The stools are 
green and frequent, scanty in quantity, and contain undigested 
particles of food. The child sufters from colic, especially soon 
after feeding; is very restless, cries and whines pitifully, sleeps 
poorly, and. do ^^•hat you will, the emaciation continues at a 
rapid pace. Before long the fontanelles, the eyes and cheeks are 
sunken ; the nose and chin pointed ; the abdomen is at first 
prominent but later retracted ; the skin wrinkled, often hanging in „ , ^ 

^ _ , ' . . Senile face; 

folds, and adding^ to this the earthv pallor and senile expression shrunken 

'^ . ' -^ . , ^ body. 

of the face, the poor creature is a sight dreadful to behold. 
Though dried up to mere skin and bone, with respiration shallow 
and pulse bad, it keeps on fighting for life for weeks and months 
— not rarely successfully. 

Unless wrecked by intercurrent diseases, those showing 
tenacity to life, and coming under observation not entirely in a 
hopeless state, stand some chance to recuperate their vitality and 
to recover completely. The prognosis depends also upon the 

( 493 ) 



494 DISTURBANCES OF METABOLISM. 

duration of the marasmus, the age of the patient — it is more 
favorable in infants over four or five months than in younger 
ones — and the care it can receive from those in attendance. The 
°™tiiS' concurrence of compHcations or sequelae, such as atelectasis, 
edema, pneumonia, colicystitis, pyelonephritis, ostitis, general 
furunculosis and the like, greatly mar the chances of recovery. 




Fig. 155. — Marasmus in a child ten months old. Note 
"senile face." (Sheffield.) 

As athrepsia almost invariably occurs in artificially fed infants, 

the line of treatment which at once suggests itself is to supplant 

^ .„ the artificial food by human milk. Indeed, throuQh such a chang^e 

Breast milk -^ ' & o 

the best miraculous improvement in the infant's condition may often be 

remedy. ^ •' 

observed within a very few days, requiring no further treatment 
to complete prompt and uneventful recovery. Wet-nursing, 
therefore, should be the treatment of choice, even if it be only 
for a month or two, after which period cows' milk feeding may 



MARASMUS. 495 

frequently, successfully be resumed. Occasionally breast milk 
does not quite agree at first; but after persistent effort by allow- 
ing the baby to nurse only from live to ten minutes at a time, and 
giving It a little plain-, lime-, or barley-water before each feeding, 
the difficulty will readily be surmounted. Lavage and colon 
flushing often act very beneficially. AMien the services of a wet- 
nurse are not obtainable (for financial or other reasons), an 
attempt should be made to feed the baby on "laboratory" milk, muk.^^ °^" 
always beginning with small quantities of weak milk-mixtures, 
and gradually increasing in quantity and quality according to 
indications. Xot infrequently whey-mixtures act kindly. With 
poor people unable to carry out any of the aforementioned sug- 
gestions, we may try — for want of or as a stepping-stone to some- 
thing better — condensed milk in mild dilution with plain- or 
barley-water ( 5ss condensed milk to oij barley-water). Indeed, 
condensed milk is often invaluable during the summer months, 
and, if found to agree with the child, should unhesitatingly be con- 
tinued until cold weather will allow a change for cows' milk. I 
cannot pass the subject without emphasizing the fact that on a 
few occasions fearfully marasmic babies were rescued from im- Artificial 
minent destruction by means of proprietary infant foods. As this 
signal success was attained after many other methods of feeding 
had utterly failed. I am looking upon it as more than a mere coin- 
cidence. In some cases "malt-soup" { q. z\) acts exceedingly well. Mait soup. 

Lavage and colon irrigation are useful in all cases. The 
latter should be employed daily; the former every alternate day, 
or more often if the return-water contains large quantities of 
mucus, and the vomiting persists. In the latter event it is often ^^^^^ ^ 
of advantage to add a little boric acid or bicarbonate of soda to 
the sterile water used for stomach washing. Of medicinal agents, 
in addition to an occasional dose of calomel, pancreatin is the 
only remedy I place some reliance upon. One or 2 grains each 
of pancreatin and bicarbonate of soda may be administered after 
feeding. 

The mouth of the infant should be kept scrupulously clean, 
and the buttocks dry and clean — to prevent stomatitis and inter- ^^J'fSgl^^ 
trigo, both of which form common complications. The child °^ posture. 
should not be left too long in recumbent posture, lest decubitus 
or passive pulmonary congestion supervene. For details of 
treatment of atelectasis, edema, and other complications the 
reader is referred to the respective chapters. 



496 DISTURBANCES OF METABOLISM. 

^"^me^ Outdoor life and plenty of fresh air while the patient is 
indoors are essential to successful management of the cases in 
question. Whenever possible the child should summer in the 
country. xAbove all, however, breast milk is the specific for 
marasmus, in the way of prophylaxis as well as cure. 
See also ''Tuberculosis," and "SyphiHs." 

RACHITIS 
(Rickets, The English Disease). 

Rickets is one of the most common affections of early child- 
hood. It prevails to a greater or less extent in almost all parts 
of the world, but shows a predilection for poorly born, poorly 
nourished (also among the well to do) and poorly housed children 
of temperate zones. The immediate cause of rickets is an as yet 
undiscovered micro-organism or toxic product (parathyroid dis- 
ease?) circulating in the blood. As its direct and most con- 
Deficiency spicuous result we have great diminution of the inorganic elements 
salts, of bones, exaggerated production of epiphyseal cartilage, exces- 
sive cell proliferation beneath the periosteum, and incomplete 
ossification of the new osseous tissue. As the disease advances 
chronic inflammatory changes occur also in the different soft 
structures (muscles, arteries, etc.) and organs (spleen, liver, etc.) 
of the body, leading to a complex pathologic entity sui generis — 
entirely distinct from any other diseased process. 

This pathogenic process is very insidious in its onset and its 
course ; hence in the beginning rickets is very apt to be overlooked, 
especially if following upon some other illness. 

As a rule, the initial symptoms are very vague, and consist of 
recurrent indigestion, restlessness and debility — a non-pathogno- 
monic group of symptoms rarely arousing the anxiety of those 
in charge of the patient as to seek medical advice. When seen by 
the physician, therefore, the disease is usually in full bloom, 
skuu'; ^opfn The skull is relatively large, the forehead broad and prominent 
an? baldness.' ^^ profile (frons quadrata). The parietal eminences project 
strongly, and the fontanelles, especially the anterior one, and the 
sutures fail to close in due time. The occiput is thinly covered by 
hair or entirely bald, and here and there yields to pressure with 
the finger (craniotabes). 

The local baldness is the result of undue pressure and friction 
of the occiput against the pillow, and the effect of profuse 



RACHITIS. 



49^ 



perspiration which is most marked at the posterior portion of the 
head. The sweating and rubbing of the head, both very early 
symptoms of rickets, in a way are correlated, and probably due to 
cranial hyperemia. 

The lower jaw instead of being rounded becomes flattened, 
and its alveolar edge turned inward. The upper jaw also is more 
or less deformed, and the teeth, which are late and irregular in 



Deformed 
jaw. 




Fig. 156. — Rachitic Frons Quadrata and Curvature of Spine. 
(Sheffield.) 



coming, are asymmetrically set, conforming with the altered shape ^^^^^^ 
of thie jaws. Owing to the deficiency in enamel the teeth soon teething, 
turn yellow, brownish or black, are streaked and brittle and sub- 
ject to rapid decay. 

The rachitic thorax is very typical in appearance. The 
clavicles are more sharply curved than in the normal, and 
occasionally infracted; the costochondral junctions are thickened, 
bead-like in shape (most marked from the fourth to the eighth 
rib), assuming in their sloping course from above downward a 
rosary-like appearance (rachitic rosary) ; the sides of the 
thorax are flattened and the sternum projects, as in birds, — hence 



Deformed 
thorax. 



Rosary. 



498 



DISTURBANCES OF METABOLISM. 



^^fSen- ^^^^ so-called "pigeon-" or ''chicken-" breast {pectus carinatum), 
breast, ^nd, finally, the lower lateral diameter is widened. 

The vertebral column, though rarely affected in mild forms of 
rachitis, invariably suffers in severe and protracted cases. The 
deformities most frequently met with are kyphosis and scoliosis. 




Fig. 157. — Rachitic Beading of Ribs, "Pot-bell}^" and Bowlegs. 
{Sheffield.) 



Kyphosis. The kyphosis or backward curvature usually extends from the 
middorsal to the sacral region. It differs from tuberculous 
kyphosis by being rounded, and in the early stages reducible when 
the child is placed upon the abdomen and the thighs are over- 
(see "Spondylitis," page 381). Rachitic lateral 
curvature or scoliosis is produced by the relatively heavy weight 
of the head upon the yielding (muscular and ligamentous insuffi- 



Differentia- 

tion from extended 

spondylitis. 



ciency) vertebral column. 



The condition is further aggravated 



RACHITIS. 



4<M) 



by allowing the patient to sit up or walk at too early an age and 
for too long periods and by the habitual unequal distribution of 
the encumbrance. As regards the latter it will be noted that 
right-handed persons usually carry their children on the left arm, 
so as to have the right hand free, and, in consequence, the right 
pelvis of the child is lifted upward, the right shoulder tilted 
downward and the middle spine shoved laterally — lateral 




Fig. 158. — Rachitic Kyphosis in a Boy 20 Months Old. 
superabundance of fat. (Sheffield.^ 



Note 



scoliosis with the spinal convexity to the left. While rachitic 
scoliosis is most frequently observed in early childhood, rickets 
undoubtedly forms also the principal cause of the so-called 
postural scoliosis of school-children, the curvature being merely 
an exaggeration of the former condition. Rachitic scoliosis is to 
be differentiated from congenital scoliosis (very rare; as a rule 
associated with other congenital deformities) ; cicatricial scoliosis 
(following operation for purulent pleurisy) ; paralytic scoliosis — 
in association with poliomyelitis, etc. (see Fig. 114) ; spondylitic 
scoliosis — usually kyphoscoliosis (see "Spondylitis," page 381) ; 



Scoliosis. 



Differentia- 
tion from 
other 

varieties of 
scoliosis. 



500 



DISTURBANCES OF METABOLISM. 



static scoliosis (in congenital or acquired shortening of one lower 
extremity). Although, as previously alluded to, rachitic scoliosis 
is reducible in its early stage, if left alone for a long period the 
deformity is apt to remain permanent, notwithstanding the dis- 
appearance of the other symptoms of rachitis. 

The extremities very rarely escape involvement. In the 

enS'rSnL ^PP^^ extremities we usually find marked enlargement of the 

epiphyses at the wrists, and less frequently at the elbow. In 

creeping infants the radius and 
ulna are often curved and som'e- 
times infracted, and in severe 
cases the hand is separated as 
it were by a furrow — "double 
jointed." Occasionally there is 
also an enlargement of the ends 
of the metacarpal bones or the 
phalanges. 

By far more marked are the 
deformities of the low^er ex- 
tremities. The soft tibia and 
fibula are ill prepared to balance 
the weight of the body. The 
flimsy fundament thus tumbles 
under its encumbrance. The 
hapless patient learns to walk 
late and with difficulty, or, as it 
were, 'Torgets" or unlearns how 
to walk. If he continues to 
walk, the tibia and fibula bend 
either outward (bowlegs — genu 
varum; O-shape), inward (knock-knees — genu valgum; 
of lower X-shape), forward (saber-blade shape), or in severe cases 

extremities. . ,.,.-. , . . a • i 

simultaneously in different directions. As in the upper 
extremities there is also an enlargement of the epiphyseal ends 
of the bones, and occasionally infraction of the diaphyses. 
Children sitting crossed-legged may present also more or less 
pronounced curvatures of the femur and pelvis. Rachitic flat- 
foot is rare. 

The course of these deformities varies. In the majority of 
mild and moderately severe cases spontaneous recovery occurs 
with improvement of general condition. On the other hand, in 




Fig. 159. — Rachitic Bow- 
legs, ■'Jug"-.shaped Abdo- 
men, and Separation of Epi- 
physes — "Double-jointed." 
{Sheffield.) 



RACHITIS. 



501 



extreme cases, where, as a rule, growth is greatly retarded, the 
curvatures persist and require forcible corrective measures. 

The muscles generally participate in the rachitic process. 
They are thin and flabby and partly responsible for the difficulty 
in sitting and walking (''pseudoparalysis"), abdominal distention pSysis. 
( ''pot-belly"), and for the constipation and prolapsu^ recti. The Pot-beiiy. 




Fig. 160. — Rachitic Knock-knees. Note also infraction of 
left femur. (Sheffield.) 



muscular insufficiency may be associated with overfatness (see 
Fig. 158) and mask the local rachitic manifestations. 

The ligaments are more or less lax allowing undue mobility at 
the larger joints, and giving rise to the abnormality known as 
"double-joints." 

Coincidently with and in a measure because of the gross 
alterations in the body framework manifold changes occur also 
in the functions and structures of other components of the body. 



Double- 
jointed. 



502 DISTURBANCES OF METABOLISM. 

The respiratory system suffers early. The contracted chest 
Respiratory coiiipresscs its contcnts and disturbs the equilibrium of the 
difficulties. |-l-^Ql-^(.i(. a.nd abdominal organs. The area of breathing space is 
reduced, hence, respiration more or less interfered with, and the 
tendency to respiratory disease greatly increased. The latter is 
favored also by the timidity of the parents to expose their deHcate 
babies to outdoor air, keeping them huddled up in poorly 
ventilated rooms and thus reduce their power of resistance to 
infection. In consequence of it slight catarrhs of the naso- 
pharynx or larynx instead of, as in the normal, yielding promptly 
to suitable treatment, persist indefinitely and lead to capillary 
bronchitis or bronchopneumonia, not rarely with fatal issue or 
greatly protracted convalescence with a predisposition to tuber- 
culous infection. As an immediate result we have also profound 
Anemia, secondary anemia — reduction of hemoglobin and red blood-cells 
and moderate leucocytosis. The child is pale, sometimes waxy in 
color; its digestion is poor; diarrhea alternates with constipation, 
the latter, however, preponderating. The liver and spleen are 
more or less enlarged and help to distend the abdomen. Rachitic 
children are very irritable, sleep restlessly, and show a e^reat 

Spasmodic . . , i-rr . j- i-.- o 

affections, disposition toward diiierent spasmodic conditions. Spasmus 
glottidis, eclampsia and tetany are frequent complications of 
severe and protracted cases of rickets, especially in very young- 
infants. 

Cases of rickets presenting the local and generaL symptoms 
here depicted usually offer no diagnostic difficulties. Less typical 
cases, however, may be confounded with cretinism, achondro- 
plasia, congenital syphilis, incipient hydrocephalus, and osteo- 
genesis imperfecta — a group of diseases which not only have 
^.^ ,. , several symptoms in common and are to a certain extent etio- 

Differential -^ r 

diagnosis, logically Correlated, but may also be associated with rickets. 

In cretinism there is marked mental deficiency; the tongue is 
thick and protruding from the mouth ; as the child grows older 
there is very pronounced disparity between its age and body 
length. 

Achondroplasia is characterized by a striking disproportion 
between the length of the trunk and extremities ; the curvature of 
the shafts of the bones is due, not as in rickets, to softness of the 
bones, but to embryonic defective development ; the fingers do not 
lie parallel as in the normal, but are spread out like ribs of an 
open fan. 



RACHITIS. 508 

The epiphyseal thickening at the ribs and the long bones of 
syphilis hereditaria, as a rule, is observed soon after birth in 
association with other symptoms of syphilis which yield promptly 
to specific treatment. 

Incipient hydrocephalus has several symptoms in common 
with rickets (separation of the fontanelles, softening of the 
cranial bones, irritability of the nerve system). In hydroceph- 
alus, however, the cranial distention is rapidly progressive in 
character, leaving the long bones of the body, which suffer most 
in rickets, almost unmolested. 

Osteogenesis imperfecta difiters from rickets in that in the 
former the bones are so soft that they can be cut and bent, 
splintered and fractured in several places. 

The importance of an early diagnosis cannot too strongly be 
emphasized, as upon it depends the prognosis, the success of 
treatment. While it is generally admitted that rachitis per se 
is not dangerous to life, and that in a number of cases sponta- 
neous recovery is possible, the indifference of the laity as well as 
the physician regarding early and persistent treatment is strongly 
to be deprecated. Spontaneous recovery is rarely complete. On 
the contrary, without suitable treatment the majority of children 
are left stunted in growth, distorted in shape and features, and bodily 

^ ' ^ development. 

depressed in spirit — in short poorly qualified to struggle for an 
existence and to compete with their fellow^men favored by good 
fortune with sound mind and body. 

Rickets is preventable by abundance of sunlis^ht and fresh Preventive 

^ , , , , ^ measures. 

air and by a mixed, nutritious diet. In the absence of contra- 
indications, children over three months of age should receive in 
addition to milk small quantities of carbohydrates ; those over six 
months also thin soups and orange-juice; those over nine months 
half of a soft-boiled egg, some beef-juice, and a little toasted 
bread with sweet butter, and those over a year one egg daily, 
some fresh vegetable soup, oatmeal gruel, light cocoa, etc., and 
occasionally a small quantity of finely scraped fresh beef (see 
page 81). Season permitting, raw milk should be given in 
preference to boiled, sterilized or pasteurized. 

Rachitic deformities may be prevented by avoiding super- 
encumbrance of the spine and extremities. Infants with incipient 
rickets should, as much as possible, be kept off their feet, and 
advantageously held in recumbent posture, allowing them to 
remain in upright position only for short periods at a time. 



Retarded 



Diet. 



Rest. 



Sunshine. 



504 DISTURBANCES OF METABOLISM. 

The suggestions just made apply as well to the management of 
further advanced cases of rickets. Here, too, sunshine and 
Nitrogenous nitrogenous diet in abundance and removal of the superincumbent 
weight of the body are the remedies par excellence. To these 
we should add hydrotherapy (sea-salt baths), massage and pas- 
sive motion, and corrective, light braces where the deformities 
persist. Operative corrective procedures should be reserved for 
deformities of over three years' standing, as slight curvatures 
usually respond to non-operative antirachitic measures. 

As auxiliaries, especially with the view of overcoming the 
anemia and the deficiency of mineral elements, the syrupus hypo- 
piiosphTSs' phosphitum compositus (U. S. P.) and cod-liver oil are of 
undoubted therapeutic value. Syrupus ferri iodidi with 
syrupus calcii et sodii hypophosphitum (N. F.) also is of 
service. 

In intractable cases organotherapy, especially the extracts of 
therapy" thyroid, thymus and pituitary glands and red bone marrow should 
be given fair trial. A sojourn at the seashore is highly to be 
recommended. 

ACHONDROPLASIA! 

(Chondrodystrophia Foetalis; Fetal Rickets; Micromelia) . 

These terms are used to designate a peculiar type of con- 
Congenitai. ggj^j^-^] dwarfism arising from early fetal arrest of growth of 
the bones that are formed in cartilage, leaving the bones that 
are laid down in membrane unaffected. Thus, we have shorten- 
ing of the extremities, and of the bones of the base of the skull, 
while the bones of the vault of the cranium and the trunk are 
normal. This peculiar chondral dystrophy produces the fol- 
lowing characteristic statural disparities : — 
extremft^es? Shortness of the extremities as compared with the normal 
abdomen^ (relatively long) abdomen; bowing of the extremities, especially 
lower, and thickening of the terminal epiphyses ; limited power 
of extension of upper extremities ; peculiar fan-like divergence of 
"^hand* the thick, uniformly sized fingers, the so-called ''trident hand"; 
marked narrowing of the pelvis ; lordosis ; protuberant abdomen ; 
narrowing of the base of the skull (''pug-nose," broadening of 
the jaws), as compared with the normal (relatively large) upper 
part of the skull. The skin and nails are normal ; the hair is soft 
and abundant in growth. Intellect is usually normal. The 



1 Though not an acquired disease, this subject is treated here in order 
to emphasize its many differences from rickets. 



SCORBUTUS INFANTUM. 



505 



great majority of cases of achondroplasia die in utero or soon 
after birth. Those who survive may attain old age. They very 
rarely exceed four feet in height. 




Fig. 161. — Achondroplasia (10 months old). Note length of trunk 
and shortness of extremities. {Sheffield.) 



SCORBUTUS INFANTUM 
(Moeller-Barlow's Disease, Acute Rickets). 

Infantile scurvy is an acute specific hemorrhagic affection of 
as yet unknown origin. It is probably due to direct microbic 
infection or toxemia resulting from intestinal putrefaction. As 
the disease occurs principally in infants from six to eighteen 
months old, the period when nutritional disturbances are most 
rampant, there is every reason to believe that malnutrition is the 



Toxemia. 



Malnutrition. 



506 



DISTURBANCES OF METABOLISM. 



Usually- 
sudden 
onset. 



most active predisposing cause. This explains also the frequency 
with which infantile scurvy is observed in infants fed on boiled, 
sterihzed or pasteurized milk (milk deprived of some of its 
nutritious qualities) or poor breast milk. 

The onset of the disease is usually sudden or, less frequently, 
preceded by malaise or digestive disturbance of a few days' dura- 




Fig. 162. — Moeller-Barlow's Disease (girl 15 months old). 
Note hemorrhage from the gums and in the skin and swelling 
of lower extremities. {Sheffield.) 



Pain. 



Pseudo- 
paralysis. 



Tumefaction. 



tion. The child is restless, cries when it tries to move itself or 
when it is being handled. This symptom is the result of pain 
and tenderness especially in the lower extremities. For fear of 
pain the patient instinctively ceases to move its limbs (pseudo- 
paralysis). Examination of the extremities soon reveals at the 
diaphyses of one or both femurs, more rarely of the tibia and 
fibula, or upper limbs, spindle-shaped, colorless, smooth, non- 
fluctuating swellings surrounding the bones. The tumefactions 



SCORBUTUS INFANTUM. 



50'; 



for the most part are due to subperiosteal hemorrhage. Ex- 
ceptionally there is bleeding also from beneath the periosteum of 
the ribs and the bones of the head (protrusion of the eyeball, in 
subperiosteal hemorrhage of the frontal bone) and face, and 
occasionally spontaneous separation of the epiphysis from the 
shaft of the bone, leading to bone infraction, impaction or frac- 
ture. The next important symptom of infantile scurvy is spongi- 
ness and discoloration (minute transient ecchymoses) of the 
gums, with a tendency to bleed. In quite a number of cases the 
hemorrhagic tendency extends also to the skin, subcutaneous 
tissue (typical "black eye" after a fit of crying or laughing, also 
discoloration and proptosis of an eye resembling that of chloroma), 
mucous membranes and the viscera (dysentery!), so that as a 
result of loss of blood profound anemia, edema and albuminuria 
supervene. On the other hand, some cases pursue a very mild 
course (formes frustes), especially if recognized early and treated 
energetically. Except occasional permanent hyperostosis of the 
affected shafts the prognosis as a whole is favorable, recovery 
usually taking place within from a few weeks to as many months. 
Neglected cases, however, may end fatally from the aforemen- 
tioned complications, or pneumonia. 

Antiscorbutic diet and fresh air form the treatment par 
excellence. Prompt improvement and rapid recovery usually 
follow the administration of fresh cows' milk, fresh fruit- juice 
(lemon, orange, or pineapple), beef-juice, and in older children 
fresh eggs and vegetables (potato puree, carrots, spinach, etc.). 
Where convalescence is protracted we may prescribe the syrup 
hypophosphites compound (U. S. P.), with extract of malt and 
cod-liver oil. 

Infantile scurvy may be mistaken for : Rheumatism, peliosis 
rheumatica, purpura hsemorrhagica, syphilitic epiphysitis, osteo- 
myelitis, rickets and occasionally (when the orbit is involved) 
for chloroma. 

In rheumatism the swelling is usually localized at the articula- 
tions and "jumps" from one place to another. It is accompanied 
b}^ fever and responds to the salicylates. Hemorrhages are 
absent. 

Peliosis rheumatica is characterized by deep red or bluish 
spots as a rule limited to the extremities. 

Purpura hccmorrhagica is free from diaphyseal hematomas 
and pain. 



Hemor- 
rhages. 



Spongy 
gums. 



Fresh, 

nourishing 

food. 

Fruit-juice. 



Cod-liver 
oil. 



Differential 
diagnosis. 



Frequent 



508 DISTURBANCES OF METABOLISM. 

Syphilitic epiphysitis is free from the hemorrhagic tendency, 
and often presents other syphiHtic lesions. 

Osteomyelitis is associated with high fever and local abscess. 

Rickets is free from acute pain and hemorrhagic symptoms. 
Has other pathognomonic symptoms. It responds very slowly to 
treatment. 

Chloroma or green tumor usually shows a predilection for the 
skull (temporal fossae and orbits), giving the child a characteristic 
frog-like appearance. It is a grave blood disease — profound 
anemia with relative and absolute increase in lymphocytes. 



DIABETES MELLITUS 

(Glycosuria). 

Within recent years, with increased interest in accurate 
in cMidren. diagnosis, the number of cases of diabetes in children recorded 
has greatly increased. In former years undoubtedly many of 
the rapidly fatal cases escaped observation. The importance of 
careful examination of the urine of older children and infants 
suffering from polyuria or enuresis, therefore, cannot too strongly 
be emphasized. 

We distinguish two forms of glycosuria: Glycosuria spuria 

diabetes, (temporary or dietetic), and glycosuria vera (diabetes mellitus). 

The first variety is comparatively of little clinical importance. It 

is the result of consumption of sugar greater in quantity than 

can be assimilated, and usually disappears after arrest of the 

causal factor. 

memtuT ^^^ ^^^ other hand, diabetes mellitus is an extremely fatal 

affection, death taking place, in violent cases, sometimes after a 

few days, weeks or months, and in less acute cases often within 

a year or two at the latest. 

^onsef ^^^ onset of diabetes mellitus is sudden. The child begins 

rapidly to lose in weight, notwithstanding good appetite, suff'ers 

from excessive thirst, passes a large quantity of urine (often 

Polyuria, euurcsis noctuma as well as diurna!), of high specific gravity 

Glycosuria (lO^O), Containing a large proportion of sugar, and loses in 

vitality from day to day. In addition to these symptoms there 

are also digestive disturbances, skin affections (furunculosis, 

onychitis), cataract, nerve disorders {e.g., often Friedreich's 

ataxia), obstinate acetone odor, dryness of the skin, etc. The 

course of the disease varies. As a rule, it is more rapid than in 



Dietetic 



DIABETES INSIPIDUS. 509 

adults; the younger the patient the more violent the course. 
Death usually occurs as a result of general exhaustion or inter- coma. 
current diseases, such as pneumonia, tuberculosis, and the like, 
and is frequently preceded by coma diabeticum or uremia. 

Recoveries, however, are also on record. Every effort should 
be made to trace the cause of the disease and to combat it 
energetically. As congenital or acquired syphilis has frequently 
been found to play an essential part in the causation of diabetes, 
it is prudent to subject the patient to a course of antisyphilitic 
treatment. Wt have no means at our command to influence the 
other supposed etiologic factors of diabetes, such as traumatism 
to the head, shock, various infectious diseases, etc. ; the time is 
not distant, however, when the true nature of the aft'ection will 
be disclosed, and the remedies found which will greatly aid us treatment! ^^■ 
in the prevention and arrest of the disease at its very inception. 
Until- this blissful moment we will have to continue groping in 
the dark, empirically treat symptoms, and depend chiefly upon a 

• • • • • Diet fr6G 

restricted diet, which at best never strikes the root of the evil, and from sugar 
is hardly practicable in diabetes of early childhood. Wherever 
possible (especially in older children), the diet should consist of 
fresh meat-soups and broths; bread and biscuits of gluten flour, 
with cream and butter ; eggs ; moderate quantities of meats of 
all kinds, with spinach, asparagus, mushrooms, string beans, cab- 
bage, radishes and turnips ; fresh sour fruit, such as grapefruit, 
lemon, cranberries and raspberries. Saccharin instead of sugar. 
In infants milk and amylacea are indispensable, but should as 
much as possible be restricted. Oatmeal gruel seems to work 
well in some cases. I\Iild hydrotherapeutic procedures and light 
exercise are useful. Aiethylatropine bromid (gr. %oo) twice a 
day, hypodermatically ; opium in some form, and arsenic, in 
addition to cod-liver oil and iron, are the only drugs of thera- 
peutic value. Complications should be treated according to 
indications. 

DIABETES INSIPIDUS 
(Polyuria). 

Polyuria, like glycosuria, may be transient or persistent, -transient or 
Transient polyuria is quite common in children and usually of persistent. 
nervous origin. On the other hand, persistent polyuria — 
diabetes insipidus — is comparatively rare. It is manifested by polyuria 
excessive thirst, polyuria (pale, sugar-free urine of low specific JJjga?^^ 
gravity), dry skin, disturbances of the digestive and nerve sys- 



.10 



DISTURBANCES OF METABOLISM. 



terns. The course is very protracted, but the prognosis quoad 
vitam favorable. Permanent recovery is rare. 

As the etiology is obscure (essentially the same as for 

diabetes mellitus), little can be expected from treatment, except 

in cases due to syphilis, which frequently yield to antisyphilitic 

treatment^ medication. Change of air, hydrotherapy, and a nitrogenous diet 

act beneficially. 




Fig. 163. — Adipositas (8 months old). Weighs 36 pounds. 
{Sheffield.) 



Spontaneous 

recovery 

the rule 

in infants. 



ADIPOSITAS 
(Lipomatosis Universalis. Obesity). 

Contrary to what is observed in older children or adults, 
overfatness in infants very rarely gives rise to constitutional 
disturbances. As a rule, the fatness subsides Avhen the child 
begins to walk about. 

In older children obesity is often associated with marked 
anemia, shortness of breath and fatty degeneration of the 



ADIPOSITAS. 



51] 



heart. If such symptoms appear, it is essential to eHminate Diet, 
fats and carbohydrates from the dietary and to recommend 
systematic exercise, active massage and hydropathic pro- 
cedures. Carlsbad salts and thvroid o-land substance are medkatioi 




Fig. 164. — Adipositas. Same case as Fig. 163, back view 
(Sheffield.) 



often useful ; some cases, however, resist all sorts of treatment, 
and readily succumb to intercurrent diseases. 

Adipositas should not be mistaken for cretinism (q. v.). 



CHAPTER XIV. 
Diseases of the Nerve System. 



GENERAL REMARKS ON CEREBRAL OR CENTRAL 
PARALYSIS AND BRAIN LOCALIZATION. 

^ ^orSraS "Cerebral Paralysis," so called, is not an independent brain 

disease, ^igease, but merely a symptom occurring in connection with a 

number of congenital and acquired brain affections. Depending 

upon the extent of the lesion the paralysis may appear either in 

the form of hemiplegia, double hemiplegia, or monoplegia. 

Unilateral Hemiplegia is the result of a lesion (disease or trauma) in 

lesion. Qjjg cerebral hemisphere. The paralysis is situated on the side 

opposite that of the lesion. Motile power may be completely 

abolished or only partially so (paresis). Sensation may remain 

intact, but is lost if the brain lesion is in the internal capsule and 

extends to the sensory fibers. The paralysis is associated with 

rfgidity? spastic rigidity of the affected muscles ; exaggeration of the deep 

reflexes ; implication of some of the cranial nerves, such as the 

^^T)?crSfiai facial (paresis), hypoglossal (deviation of the tip of the tongue to 

nerves. ]^gai|-]^y side), and ocular nerves (nystagmus, hemianopsia, and 

optic atrophy), and occasionally — in left-sided lesion — also with 

motor aphasia. As the paralysis becomes chronic the paretic 

musculature shows a tendency to arrest of development, tremor 

Athetosis, ^^d athetosis; epilepsy and mental impairment up to total idiocy 

Mental ... , , 

symptoms, make their gradual appearance. 

Double hemiplegia (diplegia) may be the result of two 
Bilateral Separate atacks of hemiplegia. More frequently it develops with 
lesion. ^^^ attack as a sequel of an extensive brain lesion in both cere- 
bral hemispheres or in the pons and medulla (affecting both 
lateral halves). If only one side of the pons is involved we have 
paraiysfs^ crossed paralysis of extremities on one side and of the facial 
nerve on the other side. 

In double hemiplegia, in addition to the symptoms enumerated 
under hemiplegia, functions may suffer which escape ordinary 
hemiplegia, e.g., that of swallowing and, perhaps, that of mic- 
turition. Occasionally it is accompanied also by paralysis of the 
(512) 



CEiNTRAL PARALYSIS. 



513 



tongue, giving rise to symptoms which closely resemble those 
associated with bulbar paralysis. However, there is no wasting 
of the tongue, nor change in the electric reaction; hence, is 
spoken of as "pseudobulbar paralysis." 

Monoplegia as a primary manifestation of a cerebral 
paralysis is rare. More frequently it is met in the regressive 
stage of the aforementioned two types of paralysis or in connec- 
tion with lesions of the spinal cord or peripheral nerves. Cere- 
bral monoplegia usually arises from a limited lesion in or near 
the cortex, less frequently from small capsular lesions involving 
individual nerve-bundles for the face, arm, leg, etc. (See also 
''Brain Localization," page 514. 

The course of cerebral paralysis differs with the gravity and 
extent of the lesion. In cases of sudden onset which survive 
the immediate attack there is usually an early and appreciable 
improvement in the motor paralysis. The spasmodic rigidity 
may considerably improve or grow worse. The choreic and 
athetoid movements usually persist. The same is true of the 
mental impairment and of the posthemiplegic epilepsy, except that 
under suitable treatment there is some fair prospect to lengthen 
the intervals between the epileptic attack. 

Cerebral paralysis may sometimes be confounded with infan- 
tile spinal paralysis affecting one arm and one leg. The diagnosis 
can readily be cleared up, however, by bearing in mind the follow- 
ing differential points : — 



Cerebral Paralysis. 

Paralyzed limb rigid. 
Tendon reaction exaggerated. 
Electric reaction normal. 
Involvement of cranial nerves com- 
mon. 
Atrophy of affected muscles slight. 
Athetosis common. 
Mentality affected. 



Poliomyelitis. 

Flaccid. 

Diminished or lost. 
Diminished or lost. 
Exceptional. 

Marked. 

Absent, 

As a rule not. 



Paralysis of 
the tongue. 



In cerebral 
or spinal 
lesions. 



Improvement 
in motor 

paralysis. 



Differential 
diagnosis. 



Monoplegia of cerebral origin differs from spinal in the same 
manner as hemiplegia. Besides, there is usually a history of pre- 
ceding unilateral or bilateral paralysis with gradual improvement. 

The treatment of cerebral paralysis is practically the same as 
in spinal paralysis : restoration of the sensory and motor power, 
and prevention of permanent deformities. Where the paralysis 
is due to local pressure (trauma, tumor, etc.), operative inter- 
ference is indicated. A thorough course of antisyphihtic medica- 

33 



514 



DISEASES OF THE NERVE SYSTEM. 



Anti- 
syphilitic 
treatment. 



tion will not rarely be found a thankful experiment — regardless 
of discernible cause. Except in syphilitic cases, however, the 
prospects of a cure are very poor. The prognosis quoad vitam 
is fair, but depends upon the cause and treatment. 



Seat of Lesion. 

Central convolutions : 

1. Upper third. 

2. Middle third. 

3. Lower third. 

(a) Upper part. 

(b) Lower part. 

Frontal convolutions. 
Parietal convolutions. 



Occipital convolutions (especially 

cuneus). 
Temporal convolutions. 

Centrum ovale. 



Central ganglia (caudate and len- 
ticular nuclei). 
Optic thalamus. 

Internal capsule. 

quadrigemina (anterior 



Brain Localization. 

Usual Manifestations and Their Seat. 

Paralysis of leg, opposite side; con- 
vulsions. 

Paralysis of arm, opposite side; 
convulsions. 



Paralysis of the muscles of one- 
half of the face. 

Paralysis of the muscles of the lips 
and tongue. 

Disturbance of speech. 

Disturbance of cutaneous and mus- 
cular sensibility. 

Hemiopia; loss of visual memory. 



Corpora 
pair). 



Crura cerebri. 

Pons and medulla (one-half), 



Cerebellum. 



Disturbance of hearing, opposite 
side, and sense of smell. 

Monoplegia, hemiplegia, hemiopia, 
word-deafness and aphasia ; con- 
vulsions. 

Hemiplegia and hemianesthesia. 

Disturbance of vision up to blind- 
ness. 

Hemiplegia and hemianesthesia, and 
sometimes loss of special senses. 

Oculomotor paralysis, reeling gait, 
possibly total blindness and deaf- 
ness. 

Hemiplegia with crossed paralysis 
of oculomotor nerve. 

Hemiplegia with crossed paralysis 
of facial nerve ; hemianesthesia : 
also involvement of other cranial 
nerves, e.g., hypoglossal, abducens, 
varying with the height of the 
lesion. 

Ataxia, vertigo, and vomiting. 



Congenital 
or acquired. 



Idiocy; 
hemiplegia. 



PORENCEPHALIA. 

Absence of brain substance may be congenital or acquired, 
occurring either as a result of embryonic arrest of development 
or of ante- or post-natal brain disease. The clinical symptoms 
arising therefrom depend upon the seat and extent of the defect, 
but generally correspond to those of pronounced microcephalus 
or hydrocephalus, i.e., idiocy, hemiplegia, diplegia, defective 
speech, etc. 



HYPEREMIA OF THE BRAIN. 515 

ANEMIA OF THE BRAIN 
(Hydrocephaloid) . 

This condition is usually the result of excessive loss of body 
fluids (repeated hemorrhages), general grave anemia, exhaus- 
tion from acute (rarely chronic) gastrointestinal diseases, inter- 
ference with the blood-supply of the brain (pressure on the part 
of tumors), etc. If the anemia is moderate, it is manifested 
principally by syncope. 

Anemia of the brain occurring in violent gastroenteric aft'ec- 
tions (with profuse vomiting and diarrhea) is generally spoken 
of as "hydrocephaloid," so designated by Marshall Hall, who 
first described the symptom-complex. Hydrocephaloid is char- 
acterized by a stage of excitation: flushed face, fever, restless- excitation; 

. . . of pros- 

ness, jactitations ; and one of prostration : pallor, sunken face, tration. 
irregular pulse and respiration, cold extremities, subnormal tem- 
perature, sunken fontanelles, stupor with half-closed eyes, hazy 
cornese, coma, convulsions, and, as a rule, death. Occasionally 
hydrocephaloid yields to energetic treatment, which consists of 
external heat stimulation by entero- and hypodermo-clysis, sterile 
camphorated oil and strychnin hypodermatically, champagne, and 
small quantities of food by mouth. Fresh air. 

The brain of infants dying from cerebral anemia is pale, 
watery and softer than normal. 

B Caffeinae natrii benzoatis gr. xij | 0.8 

Aq. clestil 3ij | 8.0 

M. Sig. : Gtt. X, In-podermatically, for a child 1 to 2 years old. 

HYPEREMIA OF THE BRAIN. 

The hyperemia may be active, or arterial ; or passive, or 
venous. 

Active hyperemia may occur as a result of sunstroke, trauma- Active, 
tism, mental or physical overexertion, overstimulation by exhil- 
arating beverages or drugs, hysteria, onset of acute infectious 
diseases, etc. 

It is manifested by deep redness of the face, congestion of the congest 
conjunctivae, contraction of the pupils, hot skin, high temperature, 
accelerated pulse, strong pulsation of the carotids and temporals, 
ringing in the ears, intense headache, excessive thirst, and in 
severe cases convulsions, delirium, distention of the fontanelles, 
and other symptoms of meningeal irritation. 



ion; 
fever, and 
convulsions. 



516 



DISEASES OF THE NERVE SYSTEM. 



Passive. 



Exhaustion. 



Sedatives; 
stimulants. 



Passive hyperemia of the brain is caused by passive conges- 
tion of the cerebi-al veins owing to cai'diac debihty, grave pul- 
monary affections (edema, pertussis, etc.), compression of the 
veins in the neck, etc. 

The symptoms of passive hyperemia are those of exhaustion, 
apathy, somnolence, cyanosis of the face and dyspnea. 

The treatment depends upon the original condition. It is 
more or less symptomatic — sedatives in active, stimulants in 
passive variety of hyperemia. 

Upon the underlying cause also depends the final outcome. 
Protracted hyperemia sooner or later leads to meningitis, rupture 
of the blood-vessels, and dropsical effusion in the cranial cavities. 



External. 
Internal. 



False. 



True. 



ACQUIRED HYDROCEPHALUS! 

(Dropsy of the Brain). 

By hydrocephalus is understood the accumulation of fluid 
within the cranium. The fluid may collect in the subdural space 
(external hydrocephalus) and be general or local ("sacculated"), 
or into the ventricles (internal hydrocephalus). 

Clinically hydrocephalus may be divided into false and true. 
False hydrocephalus embraces all forms of dropsy of the brain 
accompanying active or passive inflammatory processes the intra- 
cranial pressure of which being insufficient to produce destruction 
of the contiguous brain tissues. It includes all cases of acquired 
hydrocephalus with a comparatively slight exudation, such as 
arise in connection with inflammation of the brain and meninges 
(tuberculous and non-tuberculous), acute infectious diseases with 
cerebral symptoms, severe gastrointestinal intoxication (acute 
and chronic), traumatism during or after birth, etc. True hydro- 
cephalus is characterized by a primary deficiency (congenital!) 
or secondary (acquired!) destruction of brain tissue as a result 
of excessive pressure by a large exudation. 

The symptomatology of false hydrocephalus resembles that 
of an acute or chronic inflammatory process of the meninges, or 
brain, or both, and depends not only upon the seat and amount 
of the effusion but also upon the course of the original aft'ection. 
The principal symptoms are those of cerebral irritation, which 
may vary from simple irritability to marked convulsions, paresis, 
loss of vision, and coma. The symptom-complex is not a con- 



^ See "Congenital Hydrocephakis," page 124. 



ACQUIRED HYDROCEPHALUS. 



517 



stant one, as is characteristic of true hydrocephalus. It may vary 
from day to day and may subside entirely with abatement of the 
original cause. The shape of the skull is but little changed. In 
infants the fontanelles are enlarged and bulging and the sutures 
are slightly separated. In older children with closed fontanelles 
no perceptible enlargement is discernible, except in progressive 



In false 
hydro- 
cephalus 
symptoms 
inconstant. 




Fig. 165. — Acquired Hydrocephalus, following Acute Gastro- 
enterocolitis. Patient also suffering from rachitis. See Fig. 156. 
(Sheffield.) 



cases of long standing — in which event true hydrocephalus is then 
dealt with. 

The course of false hydrocephalus differs with the etiologic 
factors. If the exudation is moderate and due to curable dis- 
eases, e.g., gastroenteritis, traumatism, rickets, syphilis, etc., the 
further progress may be arrested and recovery occur. Some 
cases, of course, end fatally — with the underlying cause ; others 
again, as previously mentioned, are transformed into true hydro- 
cephalus, which is practically identical with "congenital hydro- 
cephalus" (q. v.). 



True hydro- 
cephalus 
resembles 
the con- 
genital 
variety. 



Syphilis. 



518 DISEASES OF THE NERVE SYSTEM. 

INTRACRANIAL HEMORRHAGE 

(Meningeal Hemorrhage, Hemorrhage in the Brain). 

We had occasion (see page 161) to direct attention to 
hemorrhages resulting from obstetrical injuries. This space will 
be devoted to the discussion of intracranial hemorrhages occur- 
ring during infancy and childhood. The usual sites for intra- 
lesion. Cranial hemorrhages are as follows : Neighborhood of the large 
central ganglia, pons, meninges, convolutions, cerebellum, crura 
cerebri or medulla. 
Trauma. They may occur as a result of trauma, such as a blow or fall 

upon the head, in association with meningitis, infectious diseases, 
purpura, pertussis (as a result of severe venous congestion), 
sinus-thrombosis, syphilis (syphilitic arteritis), richly vascular 
Increased tumors, nephritis and hypertrophy of the heart (owing to in- 
pressure. creascd blood-pressure) , etc. 

In the majority of instances the symptomatology is at first 
indefinite and inseparable from that of the fundamental disease. 
Where the hemorrhage is extensive, the symptom-complex 
Loss of resembles in its entirety that observed in intracranial hemorrhage 
ness; in adults. Thus: Unconsciousness, convulsions; slow, irregular 
breathing ; slow and full pulse, coma and death, or partial recovery 
with persistent focal signs, especially paralysis. (See "Cerebral 
Paralysis," page 512.) 

The treatment consists of an icecap to the head, counter- 
irritation, perfect rest, light nutritious diet, and, later, ergot and 
the iodids. (See also "Central Paralysis," page 513.) 



EMBOLISM OF THE BRAIN ARTERIES. 

Cerebral embolism, like hemorrhage, is rarely observed in 
Valvular children. It is occasionally met in connection with severe val- 
dis^lse' vular heart disease, and acute infectious and pyemic processes, 
and most frequently affects the arteria fossae Sylvii. 
Differentia- The Symptomatology of embolism is practically the same as in 

^'cSreK cerebral hemorrhage (q.v.), except that in the former the signs 
hemorrhage. ^^ cerebral Compression and shock are not as persistent and as 
severe. Furthermore, the existence of valvular heart trouble 
decides in favor of embolism. The onset is usually sudden 
(occasionally preceded by headache, vomiting, etc.), with con- 
vulsions, coma, etc., followed either by early death or partial 



Debility. 



Infection. 



Active. 



SINUS-THROMBOSIS. 519 

recovery, with remaining focal symptoms, especially hemiplegia 
and aphasia. 

The treatment is the same as in cerebral hemorrhage. Anti- 
syphilitic treatment may be tried in cases of doubtful origin. 



SINUS-THROMBOSIS. 

Thrombosis in the large sinuses of the dura mater is most 
frequently observed in debilitated infants. Two forms are dis- 
tinguished : Passive or marantic, being the result of retardation 
of the venous blood-current in severe cardiac, gastrointestinal, or 
other exhausting diseases ; active or infective, occurring in con- 
nection with inflammatory processes in the vicinity, e.g., ear, nose, 
eyes, etc. 

Passive sinus-thrombosis is usually limited to the longitudinal Passive, 
sinus and is manifested by symptoms of exhaustion and collapse 
and those of hydrocephaloid plus local edema and distention of 
the veins of the head and face. 

Active sinus-thrombosis usually involves the transverse and 
petrosal sinuses and is characterized, in addition to the afore- 
mentioned phenomena, by more or less marked septic symptoms 
(vomiting, chills and fever, etc.), hemorrhagic infarcts and 
embolism, e.g., in the lungs, spleen and other organs of the body. 

The differential diagnosis between the two varieties of sinus- diagnosis, 
thrombosis is quite difficult, but somewhat facilitated by lumbar 
puncture, which in the infective form reveals in the hemorrhagic 
cerebrospinal fluid numerous bacteria (strepto-, staphylo-, or 
pneumo-cocci). When the longitudinal sinus is involved we 
have: epistaxis, cyanosis of the face, frontal sweating; when the 
transverse and petrosal of one side : corresponding collapse of 
jugular vein and edema of mastoid region; when the cavernous 
sinus : exophthalmos. 

Where a diagnosis can be established early opening of the 
sinus may prove a life-saving operation in septic sinus-throm- 
bosis. Otherwise Httle can be accomplished in the way of 
therapy. In marantic sinus-thrombosis active stimulation may 
act well in some cases. The prognosis thus being so extremely 
grave, our attention should be directed principally toward 
prophylaxis, especially as regards extension of the suppurative 
process from neighboring structures. 



Differential 



Attention 
to sup- 
purative 
processes. 



520 



DISEASES OF THE NERVE SYSTEM. 



POLIOENCEPHALITIS ACUTA (STRUEMPEL) 

("Hemiplegia Spastica Infantilis," Bendix). 

encephalitis The exact status of this diseased condition is still unsettled, 
poliomyelitis. Some authors look upon it as an irregular type of encephalitis, 




Fig. 166. — Polioencephalitis. Note peculiar position of right leg in the 
act of walking, and characteristic "athetotic" hand. (Sheffield.) 



others group it with anterior poliomyelitis. As the clinical pic- 
ture is so much at variance with either of these affections, it is, 
perhaps, preferable to treat it as a clinical entity. We should 



POLIOENCEPHALITIS ACUTA. 521 

bear in mind, however, the fact that by extension of the inflam- 
matory process either downward or upward encephahtis and 
poHomyehtis, respectively, may present a more or less identical 
symptom-complex. 

Pathologically, after abatement of the acute process, it is pathologic 
manifested by sclerosis, atrophy, fatty or cystic degeneration of ^^'^^^^^• 
certain portions of the brain — of several convolutions, an entire 
lobe, or of the large brain ganglia. These lesions are vestiges of 
inflammatory, embolic, thrombotic, or hemorrhagic processes 
within the gray motor cortical substance. Not rarely the 
pyramidal tracts down to the medulla spinalis exhibit secondary 
descending degeneration. 

It is a disease of early childhood, up to four years of age, and in early 
usually develops suddenly (very rarely insidiously) with fever, 
nausea, vomiting, headache and convulsions, or, less frequently in 
connection with other infectious diseases, such as exanthemata, 
pneumonia, etc. After subsidence of the acute course it is 
noticed that one-half of the body, or one arm or one leg is more or Hemiplegia; 
less paralyzed. Sometimes there are also disturbance of speech athetosis and 
and mental impairment. As the disease progresses, the affected impairment, 
limbs become atrophied and contracted and manifest a great tend- 
ency to athetotic and choreic movements. The tendon reflexes 
are exaggerated, but the muscles never exhibit reaction of 
degeneration. Sensation is unimpaired. The cranial nerves 
{e.g., facial), as a rule, are involved, but not to a great extent. 
In course of time especially under suitable treatment (which 
is practically the same as in anterior poliomyelitis) the paralysis, 
atrophy and contractures may somewhat improve and in mild 
cases disappear entirely, but on the wdiole the prognosis is bad. 
The patients are usually helpless in mind and body, are very 
prone to suft'er from epilepsy and, where the cerebral symptoms 
are pronounced, rarely attain the age of 20 or 30 years. 

As already suggested polioencephalitis may be mistaken for Differential 
atypical encephalitis or anterior poliomyelitis. In both of the ^^^°°^'^- 
latter affections, especially in poliomyelitis, spasticity and athetosis 
of the extremities (both pathognomonic symptoms of polioen- 
cephalitis) are absent. Furthermore, in poliomyelitis there are 
reaction of degeneration and diminution or loss of tendon reflexes 
— the contrary being the case in polioencephalitis. 



522 DISEASES OF THE NERVE SYSTEM. 

ENCEPHALITIS 

(Inflammation o£ the Brain). 

Non-suppurative (Hemorrhagic) ; Suppurative 
(Cerebral Abscess). 

Encephalitis may be primary or secondary. Primary encepha- 
Trauma. jftis usually ariscs as a result of traumatism to the head or infec- 
tion by pathogenic micro-organisms, as is apt to occur in con- 
nection with divers acute infectious diseases, such as influenza, 
scarlatina, typhoid fever, measles, etc. Secondary encephalitis 
most frequently develops through extension of inflammatory or 
fuppura°uon^ Suppurative processes of neighboring structures, e.g., the eyes 
(panophthalmitis), the nose (caries of the cribriform bone) and 
especially the ears (mastoiditis) ; as a result of pyemia, pul- 
monary abscess or gangrene, ulcerative endocarditis, embolism; 
foreign bodies in the brain, etc. The encephalitis may remain 
circumscribed or become diffuse; in either case, however, it may 
go on to suppuration. 

In simple encephalitis the brain usually presents numerous 
^^"^Tesions^ miuutc hemorrhagic lesions. The larger foci at first appear red 
and soft, and later yellowish-white. After the process has run 
its course the affected part of the brain shows marked atrophy 
with cicatricial contraction. In abscess formation it is not 
uncommon to find, in recent cases, a cavity (one or several, small 
or large) filled with reddish or yellowish fluid, and in older cases 
encysted green, offensive pus. The abscess may remain encap- 
Encapsuiat^e^d gulatcd for a Variable length of time (even years), and apparently 
do no harm, but may at any time perforate the sac, allowing the 
pus to permeate the brain substance, or enter the ventricles. The 
meninges rarely escape involvement. 

The clinical picture of encephalitis is very misleading and 
varies greatly with the seat and extent of the lesion and the 
stage of the disease. It is less confusing in cases of cranial 
traumatism, but, even in as severe an injury as fracture of the 
skull, the cerebral symptoms may be so vague as for days to 
escape notice. The onset is usually sudden with nausea, vomit- 
convuiSs! ing, fever, stupor and convulsions. Older children complain of 
dizziness and headache. This condition may last one or two days 
or as many weeks. Then either the coma increases and is fol- 
lowed by death or the symptoms abate, and the patient is appar- 
ently on the road to recovery, except that in the majority of 



ENCEPHALITIS. 



523 



instances monoplegia, or hemiplegia with or without involvement 
of some cranial nerves is left behind. The subsequent course of 
the disease depends upon the nature of the brain lesion. Simple 
encephalitis or suppurative encephalitis of very limited extent, 
with its cause removed, may clear up without appreciable after- 
effects. On the other hand, where an encapsulated abscess has 
formed, the violent symptoms 
may abate and the acute pass 
into a chronic stage. This 
state reached, the encephalitis is 
apt to run a very protracted 
course, with recurrent violent 
exacerbations and deceptive 
remissions, on the one hand 
giving rise to symptoms of 
acute meningitis ; on the other, 
especially if the abscess is large 
and pressing upon the motor 
areas and cranial nerves, to 
those of tumor of the brain. 
In either case the diagnosis is 
often extremely difficult. Ordi- 
narily meningitis differs from 
abscess in that it pursues a 
more acute course, and the 
brain symptoms are indicative 
of a more diffuse lesion. The 
diagnosis between brain tumor 
and abscess is still more diffi- 
cult. In abscess there is 
usually an irregular tempera- 
ture with rigors, motor aphasia 
and paraphasia, while in tumor 
fever is rare and there is a 
greater tendency toward dis- 
turbances in the area of distribution of the cranial nerves at 
the base of the brain, and toward choked disk. (See "Brain 
Tumor," page 524.) A history of ear disease or direct violence 
points strongly toward abscess. Slowly developing focal brain 
symptoms are characteristic of brain tumor. These differential 
points, however, at best, are not very reliable. 



Paralysis. 




Fig. 167. — Encephallll^.. with 
Left Hemiplegia. Note droop- 
ing of left shoulder and drag- 
ging of left leg in the act of 
walking. (Sheffield.) 



Differentia- 
tion from 
meningitis 
and brain 
tumor. 



Latent 
course. 



524 DISEASES OF THE NERVE SYSTEM. 

As previously mentioned the remissions occurring during the 
course of chronic brain abscess are very deceptive. In the first 
place, the ''latent period" is rarely entirely free from signs of 
ill health. As a rule, the patient suffers from occasional head- 
ache, vomiting, rise of temperature, mild paresis, etc. Secondly, 
there is no way of telling when in the midst of apparent good 
rupture o^ health the abscess may suddenly rupture in the brain ventricles 
or meninges and rapidly end fatally. 

The prognosis of brain abscess, therefore, is always very 
grave, unless surgical interference is resorted to early. The 
operative results are especially favorable in abscesses due to 
treatment, otitis or trauma — provided they can be localized. 

Hemorrhagic encephalitis, or purulent encephalitis before 
operation, should be treated by perfect rest, icebags to the head, 
lumbar puncture, etc. — the same as acute meningitis. Treated in 
this manner primary, simple encephalitis not rarely terminates in 
recovery. 

Early prophylactic measures, particularly energetic treatment 
to ear of ear trouble, scrupulous attention to suppurative conditions of 

disease. . , . , . - , 

the eyes, nose and throat are all powerful m the prevention of the 
dreadful complications and sequelae. 

TUMORS OF THE BRAIN. 

Of the total number of cases of brain tumors on record about 
one-half occurred in children. Brain tubercle is especially com- 
mon, and relatively frequent also are divers forms of sarcoma 
(gliosarcoma). Hidden as intracranial neoplasms are from 
sight and touch, their nature must necessarily be a matter of 
conjecture only, except, perhaps, in cases of bony growths, which 
may be diagnosed by means of the X-ray, and tubercle and 
syphilis, which may be surmised by the presence of other tuber- 
culous or syphilitic lesions in other parts of the body or detected 
by the tuberculin or Wassermann's tests. 

The diagnosis of brain tumor is based upon the general and 
local nerve disturbances they produce. As a rule, the general 
symptoms precede the local, and consist of : Headache, vomiting, 
vertigo, optic neuritis, and convulsions. 

The headache is usually persistent, but may also be periodical, 
suggesting a malarial origin. The headache may be frontal, 
vertical or occipital, or equally distributed over all parts of the 
cranium. The locality of the pain occasionally bears a direct 



Tubercle. 



Gliosarcoma. 
Gumma. 



Headache. 



TUMORS OF THE BRAIX, 



525 



relation to the seat of the tumor, thus : when the growth is in the 
white substance the pain is usually frontal; when beneath the 
tentorium, occipital,, etc. The same rule often applies to the 
pain elicited on tapping the skull over the seat of the disease. 
Intense headache in infants is indicated by rolling of the head 
from side to side,, by throwing the hands up to the head, contrac- 
tion of the eyebrows,, and intolerance to light. The headache is 
frequently followed but may also be preceded by vomiting. vomiting. 

The vomiting is projectile in character, and comes on sud- 
denly. It differs from gastric vomiting by the absence of other 
signs of stomach trouble, and from vomiting accompanying 
migraine by the fact tliat the headache does not always terminate 
with it. A'omiting is especially characteristic of tumor in the 
medulla oblongata and in the middle lobe of the cerebellum, but 
it may occur in tumors aft'ecting any part of the brain. 

The vertigo may be constant or paroxysmal and is most vertigo, 
marked in aft'ections of the pons or cerebellum. \'ertigo in 
infants frequently escapes notice. It is manifested by sudden 
drooping of the head, pallor of the face and occasionally also 
vomiting. 

Optic neuritis sometimes forms one of the earliest svmptoms optic 

r 1 • T 1 1 •> ' • r neuritis. 

of bram tumors, it does not always correspond to the size of 
the tumor. The neuritis is usually bilateral. It may develop 
slowly or rapidly, and in either case proceeds to complete optic 
atrophy. 

The child's nerve system being highly susceptible to irritation, 
increased intracranial pressure is quite early productive of con- 
vulsions of varying severity. The convulsions may be general 
or local. General convulsions with loss of consciousness may 
occur in tumors of any part of the brain, but are more common 
in tumors of the posterior fossa than in those of the anterior 
or middle fossa. Local convulsive seizures are met with chiefly 
when the neoplasm occupies certain situations. For example, 
convulsions beginning in the foot, as a rule, are indicative of the 
lesion being in the upper region of the motor area ; those of the 
arm. the middle region, and those of the face, the lower region. 
It should be remembered, however, that the effects of a tumor 
may extend far beyond its actual site, and, furthermore, as the 
case proceeds, convulsions which from the outset have been local 
may become general. The convulsive attacks may recur fre- 
quently and last from several seconds to as many hours. The 



526 



DISEASES OF THE NERVE SYSTEM. 



Paralysis. 



Differentia- 
tion from 
tuberculous 
and 
syphilitic 
meningitis; 
brain 
abscess and 
epilepsy. 



convulsions are not rarely followed by paresis or paralysis of the 
affected limbs. At first the muscular weakness may be transient, 
but as the disease advances it becomes permanent. 

The focal symptoms of brain tumors are manifested by uni- 
or bi-lateral hemiplegia, monoplegia, affections of speech, and 
paralysis of cranial nerves. The local symptoms pointing to 
the seat of a tumor attain their greatest precision when the swell- 
ing — be it a new growth or an inflammatory mass — is seated in 
the motor area of the cortex. They do not always correspond, 
however, to the size of the tumor. Furthermore, as the brain 
usually accommodates itself to the gradually increasing pressure 
and functional interference produced by the new growths, the 
appearance of the focal symptoms is frequently delayed until a 
very late stage of the disease. Once established, local symptoms 
are of great help in arriving at a correct diagnosis, except, per- 
haps, in cases where the tumor is multiple and distributed through 
various parts of the brain {e.g., tuberculosis). See "Brain 
Localization," page 514. 

With the determination of the seat of the tumor, the diag- 
nosis is greatly facilitated but rarely entirely settled. Brain 
tumors have several symptoms in common with tuberculous 
and syphilitic meningitis, brain abscess, epilepsy and hysteria; 
the differentiation between tuberculous and syphilitic tumors and 
chronic tuberculous and syphilitic meningitis is extremely diffi- 
cult and often impossible, especially when the tumors are multiple. 
In tubercle and gumma the symptoms are more gradual in 
development, the optic atrophy more pronounced and the focal 
symptoms more marked and localized, while the course of tuber- 
culous or syphilitic meningitis is more rapid. In brain abscess 
optic neuritis is less common, there is usually a history of ear 
disease, and after a period of "latency" it is usually accompanied 
by severe cerebral symptoms, fever and rigors (see "Encephalitis" 
page 522). Jacksonian epilepsy may resemble brain tumor in its 
early stage, but as the disease advances the diagnosis can readily 
be cleared up by the absence of optic neuritis and other focal 
symptoms. There are cases on record of hysterical hemiplegia 
with convulsions, and contractures which were mistaken for brain 
tumor. Careful investigation, however, will usually reveal the 
absence of optic neuritis, and the fact that in hysteria the symp- 
toms are inconstant and multifarious, rather sudden in develop- 
ment and rarely progressive in character. 



Anti- 
syphilitic 
treatment. 



Tonics. 



SYRINGOMYELIA. ,527 

The nature of the tumor can sometimes be estabHshed by its Detection of 

■^ nature 

seat. Thus, if the tumor is located in the cerebellum or pons, it °^ tumor, 
is probably tubercle or glioma; if in the cortex, it is apt to be 
syphilitic. Cysticerci are most commonly met in the meninges or 
cortex. Abscesses are usually situated in the cerebral or cere- 
bellar "hemispheres," and but rarely in the central ganglia, the 
pons, medulla, or the middle lobe of the cerebellum. 

In view of the possibility of the tumor being syphilitic, it is 
always advisable to put the patient on an active antisyphilitic 
course of treatment (iodids and mercury, page 606). In syphi- 
litic disease prompt treatment will soon be followed by ameliora- 
tion of the symptoms, and, if faithfully persisted in, often by a 
cure. This therapeutic measure is occasionally attended by favor- 
able results also in growths other than syphilitic, and should, 
therefore, be resorted to as a routine procedure in all obscure 
brain lesions. 

Should antisyphilitic treatment prove negative, and tonics 
in the form of fresh air, generous diet, cod-liver oil, iron and 
the hypophosphites fail to benefit the patient — tonics often do 
well in tubercle, and if employed early may in exceptional cases 
arrest its growth — the question of surgical interference should be 
taken under advisement. An operation is indicated where the ^^^^ '°°' 
tumor is single, and situated superficially in a part of the brain 
(motor area of the cortex) which can be reached and from which 
the tumor can be removed without immediate danger to life. 
Under favorable conditions, an operation should be performed 
early, before the general health has greatly suffered and per- 
manent injury has resulted to organs and limbs from persistent 
brain pressure. Recently successful attempts have been made to 
remove growths from deeply seated structures ; the results as 
to life and eventual cure, however, are still too few and too far 
between to warrant precipitate action. 

In hopeless cases morphine and its derivatives will help to 
relieve agony. 

SYRINGOMYELIA. 

Cavities in the cord may occur primarily as a congenital arrest congenital 
of development or secondarily as a result of a gliomatous process aJquired. 
in the gray (cervical enlargement) and white matter. In pro- 
nounced non-congenital cases it is manifested by gradual loss of paralysis. 
power in the upper limbs, trophic disturbances in the skin, sub- 



528 DISEASES OF THE NERVE SYSTEM. 

chS|es° cutaneous tissue, and bones (glossy skin, ulceration and necrosis 
of the phalanges), disturbance of sensibility (partial or complete 
loss of pain- and temperature-sense, while the muscular and 
tactile senses are preserved). Later, signs of muscular atrophy — 

Atrophy, beginning with a small muscle of the hand and gradually extend- 
ing up to the shoulder — and paralysis, first of the upper then of 
the lower extremities, set in. The course of the disease is slow 
and occasionally interrupted by stationary periods. 



SPINAL HEMORRHAGE. 

The hemorrhage may be outside the dura, in the membranes, or 
traumauZ in the substance of the cord. It is usually of traumatic origin — 
instrumental delivery, a fall or blow, severe convulsions. The 
history of the case, therefore, is valuable in the diagnosis. Slight 
hemorrhage may give rise to no definite symptoms. The diag- 
nosis of severe hemorrhage is based on the sudden appearance of 
intense pain in the back, rigidity of the spine, sometimes convul- 
Pressure sions and, if the pressure upon the cord is marked, paralytic 
symptoms (see "Myehtis"). The latter are especially pronounced 
in hemorrhage into the substance of the cord. Where the hemor- 
rhage is moderate and the patient survives the immediate attack, 
the tendency of the affection is toward recovery. This may be 
enhanced by absolute rest on the face or side in a somewhat 
prone position. Local abstraction of blood, ice to the seat of the 
injury. Later, attention to the palsy. 



symptoms 
Paralysis 



SPINAL MENINGITIS. 

In the majority of cases inflammation of the meninges of the 
spinal cord is associated with that of the brain (see "Cerebro- 
spinal Meningitis," page 335). Occasionally, however, the inflam- 
mation is limited to the spinal membranes, like spinal hemorrhage, 
being produced by traumatism. 

The symptoms of spinal meningitis are practically the same as 
rigidity and j^ Spinal hemorrhage, except that the former aft'ection is marked 

paralysis. ^ o ^ r- 

by a sharp rise in temperature at the onset, and by a more 
progressive character of the symptoms. Recovery is exceptional. 
The treatment is symptomatic. 



Pain, fever, 



SPINAL PARALYSIS. 



529 



SPINAL PARALYSIS 

(Poliomyelitis Anterior, Infantile Paralysis). 

As the name indicates the pathologic anatomy of this affection 
consists of multiple inflammatory foci (hyperemia, edema, infil- 
tration of the small cells, swelling and cloudiness of the ganglion 
cells, destruction of the nerve elements, etc.), principally in the 
gray substance of the anterior horns of the spinal cord. Occa- 
sionally the inflammation extends to the anterolateral tracts and 



Lesions 
principally 
in anterior 
horns. 




Fig. 



168. — Anterior Poliomyelitis, Involving Right Arm. 
Note atrophy. (Sheffield.) 



posterior horns, and while, as a rule, the lesion is limited to the 
cervical or lumbar enlargement or both, it may be found also in 
other regions of the cord and even in the medulla and pons — hence 
the diversity of the symptomatology. 

After abatement of the acute inflammatory process, some of 
the affected portions of the cord usually (there are but few 
exceptions) remain more or less permanently injured (atro- 
phied), and it is upon the extent of this permanent — and not upon 
the initial — lesion that the further course of the disease depends. 

It is now generally agreed that the disease, whether it occurs 
sporadically or in epidemic form, is the result of invasion of the 

34 



Spontaneous 
recession 
of inflam- 
mation. 



530 



DISEASES OF THE NERVE SYSTEM. 



spinal cord by a micro-organism or its toxin. The onset is 
Microbic usually suddcn. The local symptoms are preceded by systemic 
ongm. nianifestations, such as rise of temperature, headache, muscular 
pain, drowsiness, sometimes convulsions and other grave cerebral 
symptoms. This initial stage may last from a few hours to sev- 
eral days and as the general symptoms disappear they are being 




Fig. 169. — Poliomyelitis, Involving Right Leg. Note "foot-drop. 
(Sheffield.) 



replaced by the typical phenomenon of the disease — flaccid paral- 
ysis. The paralysis usually afifects either both legs and one arm, 
one leg and one arm on opposite sides or very rarely on the same 
side, or both legs and both arms. Occasionally one extremity is 
affected, or only the muscles of the neck or abdomen. The paral- 
ysis is usually complete. The reflexes, both superficial and deep, 
are almost invariably lost. The faradic reaction is lost early, 
while the galvanic persists for some time. The paralyzed limbs 
are limp, flaccid, cool, and at times also cyanotic. The sphincters 
are almost always intact. In uncomplicated cases sensation is 



Sudden, 

complete, 

flaccid 

paralysis. 



SPINAL PARALYSIS. 



)31 



neous 
recession of 



undisturbed, and there is no tendency to the formation of bed- 
sores. The paralysis does not remain long in its original inten- sponta 
sity. Consonant with the abatement of the inflammatory process p|rSys"i 
in the spinal cord, which usually occurs within a week, the paral- 
ysis begins to recede in one or more of the affected limbs, and at 
the end of a few weeks it is often limited to one or part of one 
extremity, to a group of muscles, or, in exceptional cases, to one 




Fig, 170. — Poliomyelitis, Invohing the Neck. Note forward 
"head-drop." (Sheffield.) 



or two muscles. If the paralysis does not disappear within the 
hrst few weeks or months, it usually persists for life. The per- 
manently paralyzed structures soon begin to waste and undergo Atrophy, 
fatty degeneration. The muscles are flabby and thin and the 
articular bands so lax that the limb appears elongated and is 
prone to slip out of joint. Frequently there is also atrophy of 
the bones. 

As an immediate result of the atrophy of the diseased parts 
and the unopposed action (contraction) of the non-paralyzed contractures 
antagonistic muscles, the affected extremities become contracted 



532 DISEASES OF THE NERVE SYSTEM. 

and deformed — ordinarily for life, unless prevented and remedied 
Deformities, by orthopedic and operative procedures. The deformities in the 
legs usually occur in the following order of frequency : Talipes 
equinus, equinovarus, equinovalgus, calcaneus or calcaneovalgus, 
and talipes varus. Manifold deformities arise also in the arms, 
neck and vertebral column from paralysis of the respective 
muscles (see Fig. 114). This is the typical course of the disease. 




cases. 



Fig. 171.— Anterior Poliomyelitis, Affecting Right Leg. Note 
atrophy and flaccidity of knee-joint. {Sheffield.) 

Atypical Deviations from the typical course of the disease are not rare, 
and every epidemic is prone to present certain peculiarities. 
Thus, the onset may be either very mild or exceptionally severe. 
Where the onset is mild, the child may be found hopelessly 
maimed abruptly in the midst of perfect health. On the other 
hand, not rarely the initial stage is ushered in with vomiting, con- 
vulsions, stupor and similar meningeal symptoms, and continue 
for a week or so before reveahng the exact nature of the affec- 
tion. Furthermore the paralysis may develop in stages — at irreg- 
ular intervals. In some cases paresthesia prevails; in others 
anesthesia — showing implication of the gray substance of the 
posterior horns. Occasionally the muscles of deglutition and 



SPINAL PARALYSIS. 



533 



respiration are affected, and where the lesion is situated in the 

medulla oblongata and pons the clinical picture of "polioen- po^oe^^!*^^ *^ 

cephalitis" (facial palsy, etc.) develops. Finally, some epidemics cephalitis. 




Fig. 172. — Paralytic Equinovarus in Poliomyelitis of Twu Years' 
Standing. (Sheffield.) 

are distinguished by prompt and complete recession of the appar- 
ently genuine paralysis. 

Typical, fully developed spinal paralysis is strongly character- 
istic and presents no diagnostic difficulties. The initial febrile 
stage, the sudden appearance and spontaneous partial recession of 



534 



DISEASES OF THE NERVE SYSTEM. 



Patho- j-j-je paralysis, the almost constant integrity of the sphincters and 

symptoms, ^^i^ sensory sphere, the abolition of the reflexes and the electric 

(faradic) reaction and, finally, the appearance of muscular atro- 




Fig. 173. — Anterior Poliomyelitis, hivolving Extremities, Face and 
Abdominal Muscles. (Sheffield.) 



phy furnish a clear clinical picture. However, in the absence of 
an epidemic and where the case runs an atypical course, polio- 
myelitis, especially in its early stage, may be confounded with : 
Cerebral paralysis, polioencephalitis, myelitis, diphtheritic paral- 



SPINAL PARALYSIS. 535 

ysis, and other affections associated with muscular and neural 
hyperesthesia and consecutive immobility of the aft'ected limbs. 
The dift'erence between cerebral and spinal paralysis has 
already been spoken of (see "Cerebral Paralysis," page 512). 
Severe poliomyelitis and mild polioencephalitis have many symp- 
toms in common, and their differentiation is based principally Differentia- 
upon the facts that in polioencephalitis the tendon reflexes are poiioen- 
exaggerated and the muscles never exhibit the reaction of degen- myemisl^' 

T- 1 • • 11 ■ 1 .1 . • 1 diphtheritic 

eration. Lurthermore, spasticity and choreic and athetoid move- palsy, 
ments which are characteristic of the latter aff'ection are absent scurvy, 
in poliomyelitis. In jtiyclitis the sphincters and the sensory plfaiysis 
sphere are almost invariably aff'ected, and decubitus is quite com- progressive 
mon. Diphtheritic paralysis is preceded by diphtheria, is dis- atrophy, 
tributed symmetrically, and does not recede en masse, as is typical 
of polionn'elitis. During an epidemic, when our judgment is 
apt to yield to the anxiety not to miss the mark, rheumatic aff'ec- 
tions and scurvy may occasional^ be mistaken for spinal paral- 
ysis. The presence of other rheumatic symptoms (tumefaction 
of the aft'ected muscles or at the joints) in rheumatism and 
hemorrhages from the gums, etc., in scurvy, and, particularly, 
the absence of genuine paralysis in both diseased conditions are 
decisive. 

Chronic poliomyelitis may occasionally be confounded with 
Landry's paralysis (peculiar progress of the paralysis — no reces- 
sion — normal electric reaction) and progressive muscular dys- 
trophy (apparent hypertrophy in some muscles and atrophy in 
others, characteristic waddling gait, family proclivity to the 
disease. (See also page 545.) 

AA^ith an early diagnosis we are frequently in position to limit 
the lesion to the primary focus and in part prevent all such 
deformities as arise from too early and strenuous use of the -^^^^ .^ 
aft'ected limbs. During the initial stage — i.e., if the nature of ^^'^• 
the aft'ection can at all be surmised — all such measures should be 
adopted as will insure perfect rest to the mind and body of the 
patient. The diet should be bland, the bowels kept open, the 
kidneys and skin active (principally by warm baths) and the J^^ths^ 
patient preferably isolated, both to avoid transmission of the 
disease to others and to facihtate the enforcement of absolute 
restfulness of the patient. Medicinally, in addition to the warm 
baths, I place a great deal of reliance upon the abortive and g^ii^^yj^tes 
curative value of the salicylates. It should be given in moderately 



536 DISEASES OF THE NERVE SYSTEM. 

large doses all through the initial stage, and be followed by small 
doses of sodium iodid for a period of about six weeks. Me- 
dicinal nerve-tonics are in order later. As soon as the febrile 
symptoms have disappeared it is advisable to institute a course of 
local treatment consisting of gently stimulating baths, gentle 
Massage, massagc, passivc motion — to bring the paralyzed muscles into 
action — and the galvanic current (two or three times a week 
with the negative pole on the spine and the positive over the 
affected structures). This treatment should be continued for 
months. To prevent severe deformities of the lower extremities 
it is best to keep the patient off his feet for several months — until 
the paralyzed muscles have at least in part recovered their 
strength through the aforementioned mode of treatment. Above 
all, the child should not be allow^ed to run about without some 
appliances'? sort of orthopcdic apparatus to counteract the contraction of the 
antagonistic muscles. Old deformities demand surgical inter- 
ference (tenotomy and tendon-transplantation) followed by the 
roborant mode of treatment just outlined. Persistence in the 
treatment is the keynote to success. 

^. Natrii salicyl 3iss 6 

Strychninas sulph gr. ^ 0.016 

Elixir simplicis §.j 30 

Aq. destil q. s. ad f Si j 60 

M. Sig. : 3j every three hours for a child 4 years old. 



MYELITIS. 

This affection is occasionally observed in children principally 

as a result of traumatism, syphilis and compression of the cord by 

tuberculous masses and exudates between the dura and vertebrae 

secondarily to spondylitis. The pathologic process in the cord 

Pathologic varies with the etioloe^ic factors. Ordinarily the diseased portion 

findings. ^ •' 

at first is red and soft, and later yellow, fatty degenerated, atro- 
phied and sclerosed. The lesion may be situated in any part of 
the cord and accordingly the symptoms differ with the locaHza- 
cervicai. .(-ion. Thus, in disease of the cervical region there is first 
involvement (motor paralysis and sensory disturbances) of the 
upper extremities, then of the lower, and, if the lesion is very high 
up, the diaphragm also is affected and respiration is interfered 
with. In disease of the dorsal portion there is paraplegia (with 
muscular rigidity), with exaggeration of the reflexes, anesthesia 
of the extremities, paralysis of the bladder and rectum and 



Dorsal. 



ATAXIA HEREDITARIA. 537 

decubitus. In myelitis of the lumbosacral res^ion the paralysis, Lumbo- 

•^ ^ ^ r J ' sacral. 

etc., is the same as in the former lesion; but the muscles are at 
first flaccid, then show degenerative changes to electric tests, 
then waste, and the skin and tendon reflexes are alike abolished. 
The feet fall into an extended position, so that the instep is on a 
line with the tibia. In partial myelitis the symptoms are less 
pronounced, extending only to such structures as are innervated 
by the diseased segment of the cord. In unilateral lesions the 
symptoms, of course, are limited to the side affected. 

The onset may be sudden or slow, according to cause. Acute 
cases set in with chills, moderate fever, nausea, sometimes 
vomiting and convulsions, radiating pain in the back and legs, 
rapidly followed by the aforementioned typical signs. Cases with 
gradual onset, e.g., secondarily to spondylitis or compression by 
extraspinal growths, are manifested by gradually progressing 
debility of the muscles supplied by the spinal nerves below the 
compressed area, neuralgic pain, and disturbance of the bladder. 

If the primary affection (e.g., syphilis) can be reached and 
remedied before destruction of the cord has advanced too far, the 
progress of the disease can readily be arrested. Otherwise the ?/eTtment*^*^ 
symptoms continue to grow worse and at best can only be im- 
proved by massage, passive motion and faradization, procedures 
which are generally employed in all forms of chronic paralysis. 
Attention should be paid to the bladder (catheterization) and 
bowels, and particularly to the skin, as the tendency to the 
development of bed-sores is very great. 



ATAXIA HEREDITARIA (FRIEDREICH); HEREDO- 
ATAXIE CEREBELLEUSE (MARIE). 

This family affection which is traceable through several gen- 
erations is of obscure origin. Syphilis in the parents is the most °^J:|^^^j 
probable cause. The anatomical lesion — degeneration — is sit- syphilis. 
uated principally in the cord (the column of Goll, and partly also 
of Burdach and Clarke) and in some cases also in the cerebellum. 
The cord as a whole is very thin and small, i.e., arrested in 
development. 

The disease attacks the patient insidiously, between the sixth 
and fifteenth years of Hfe, with symptoms of simple progressive progressive 
inco-ordination of the lower limbs, trunk, and arms — irregular i?o^°"°^^'^^' 
swaying resembling that of chorea. Gradually the tabetic-cere- 



538 DISEASES OF THE NERVE SYSTEM. 

'^^^^^gau^ bellar gait develops, so that the child is ultimately unable to walk 
or stand. As the disease progresses, speech becomes peculiar, 
slightly scanning, heavy and awkward, vision disturbed by 
nystagmus, and occasionally optic atrophy (Argyll-Robertson 
symptom is absent, while Romberg's is occasionally present), the 
face expressionless, the general musculature paralyzed, atrophied, 
pa?aijSs^ the spinal column curved, the feet humpy-looking with the toes 
turned up {Friedreich's foot), and, finally, intelligence impaired. 
Unprovoked and uncontrollable laughter is said to be character- 
istic of the disease. As a rule, sensation and the cutaneous 
impairment TeAexes remain undisturbed; the sphincters intact until very late, 
while the tendon reflexes are abolished. The course of the dis- 
ease is very chronic. The patient is usually bedridden after a 
period of from five to ten years, but he may continue to live in 
this state another ten years. 

DISSEMINATED SCLEROSIS 

(Multiple Sclerosis). 

The etiology of diffuse and disseminated sclerosis is not 
definitely known. It is either congenital, and traceable to 
alcoholism or syphilis in the parents, or it is met in young, appar- 
ently healthy and normally developed children some time after 
traumatism or an attack of an infectious disease. 

Its onset is usually insidious with disturbance of motion, loss 

Loss of •' 

memory; of memory, and dullness of intellect, soon to be followed by 

scanning -^ , . -^ 

speech; defective speech (at first slow and later scanning), hearing, and 

sp&stic ^ , - . 

paraplegia, yisiou (uystaguius, amaurosis, and strabismus), spastic paraplegia 
(weakness and rigidity first of the upper extremities, then of the 
lower; exaggerated tendon reaction and ankle clonus) and inten- 
tion tremor. In the later stages of the disease the patient loses 
control of the bowels and bladder, suffers from difficult deglu- 
tition, and attacks of vertigo, loss of consciousness and convul- 
sions, and finally enters into a state of mental and physical 
exhaustion, paralysis and idiocy. Death occurs after several 
years. 

The symptoms just enumerated do not all prevail in every 
case. They differ with the location of the sclerosed patches. As 
a rule, the latter are found not only in the brain but in the 
medulla and spinal cord as well — chiefly in the white substance. 
The disease is very rarely influenced by treatment. Antisyphilitic 
medication, however, is worth trying. 



CONGENITAL RIGIDITY OF LIMBS. 



539 



CONGENITAL RIGIDITY OF THE LIMBS 

(Little's Disease). 

The nature of spastic spinal paralysis is still obscure. Degen- 
erative changes have frequently been found in the pyramidal 




Fig. 174. — Little's Disease. "Scissors-gait'" or cross-legged 
progression. (Sheffield.) 



tracts or their correlative structures of the encephalon. But 
whether these are the results of early antenatal arrested develop- 
ment (porencephalia), intra-uterine disease, traumatism during 
labor (embolism or hemorrhage), or simple prematurity are 
questions awaiting correct solution. Some cases are certainly 
acquired. 

The symptomatology of this affection is sometimes manifested 



Lesions in 
pyramidal 
tracts. 



540 



DISEASES OF THE NERVE SYSTEM. 



Rigidity. 



Tiptoe-gait. 



Scissors- 
gait. 



shaped 
hand. 



Symptomatic 
treatment. 



Differentia- 
tion from 
polioen- 
cephalitis. 



soon after birth and sometimes not until the child begins to walk. 
One of the earliest symptoms is rigidity of the limbs. The child 
usually lies motionless (does not kick) with the legs pressed 
against each other or one upon the other. He begins to walk 
late and with difficulty or may not walk at all. If he is able to 
walk, he takes short rigid steps with the feet in tiptoe position, 
and the knees pressed closely together or crossing one another, 
sometimes half running so that at every step a fall seems immi- 
nent. The rigidity gradually grows worse, leads to fixed defor- 
mities and extends to the upper extremities and even the trunk. 
A Z-shaped deformity is often observed in the hand when the 
patient attempts to use it. Early in the disease the deformities 
disappear during sound sleep or deep anesthesia. The knee-jerk 
is exaggerated, ankle clonus is generally present, atrophy is 
slight and develops late and the sphincters are normal. The 
majority of cases present symptoms of defective psychical 
development (up to idiocy), stammering nystagmus, strabismus, 
athetosis and epileptic convulsions. Where the latter symptoms 
prevail, the prognosis is very bad, otherwise it is not absolutely 
unfavorable. Under suitable treatment — stimulating baths, pas- 
sive motion, massage and galvanization and later immobilization 
in the corrected position for a period of months, and, if this fails, 
tenotomy, tenectomy and tendon transplantation followed by the 
aforementioned therapeutic measures — the progress of the disease 
may be arrested and a partial cure obtained. Antisyphilitic 
medication is sometimes beneficial. 

The differential diagnosis between this disease and polio- 
encephalitis is based principally upon the absence (in Little's dis- 
ease) of true paralysis and the presence of the characteristic, 
jerky, half-running, spastic scissors-gait. 



Tubercle. 



Gumma. 



TUMORS OF THE CORD AND MEMBRANES. 

Neoplasms of the cord are very rare and, hence, principally of 
pathologic and diagnostic interest. They may be primary (some- 
times congenital) or secondary. Tubercle is the most frequent 
variety observed; next in frequency are gliomas, syphilomas, 
lipomas and sarcomas. 

The symptomatology depends upon the seat of the growth, 
essentially resembling that of myelitis, except that it is of gradual 
development. In benign unilateral tumors the symptoms (motor 



PERIPHERAL FACIAL PARALYSIS. 541 

and sensory paralysis) are limited to the side affected. Anti- 
syphilitic treatment deserves full trial, and, if this fails, operative 
interference should be resorted to. 



PERIPHERAL FACIAL PARALYSIS 

(Bell's Palsy). 

Facial paralysis may be due to trauma, pressure and irrita- 
tion (swelling or disease) from contiguous structures, or ex- 
posure to cold or draughts. 




Fig. 175. — Peripheral Facial Paralysis — Bell's Palsy. Note 
inability to close right eye and drooping of right lower lip. 
(Sheffield.) 

The symptomatology is essentially alike in all cases irrespec- 
tive of cause. The paralysis is usually unilateral and affects the 
muscles of the forehead, the orbicularis oculi and some of the 
lower facial muscles. As a result of it the paralyzed side of the 
face is lax and expressionless, the nasolabial fold more or less 
effaced, the eye remains widely open and the angle of the mouth 
droops. The paralysis becomes especially pronounced, when the 
muscles are thrown into action, e.g., on laughing or crying. In features. 
severe cases there is also paresis of the soft palate, and impair- 
ment of speech and mastication, and occasionally dullness of taste 
and diminished secretion of saliva. In otic facial palsy there 
may be disturbance of hearing (hyperacuteness). In the so- 



Inability to 
close 
affected 
eye. 



Otic. 



542 DISEASES OF THE NERVE SYSTEM. 

Rheumatic. Called rheuiiiatic variety (due to exposure), the onset is usually 
sudden and accompanied by neuralgic pain. The electric reaction 
remains normal in mild cases, but is diminished or lost in grave 
cases. 

The prognosis and treatment depend upon the etiologic fac- 
Traumatic. tors. Traumatic, especially obstetric facial palsy {q.v.), where 
the trauma is slight, usually ends favorably within a few weeks — 
without any therapeutic measures. 

Facial palsy arising from involvement of the facial nerve by 
aural suppurative processes (middle ear disease; caries of the 
petrous portion), usually runs a more protracted course, often 
long after removal of the cause. Early attention to the ear 
affection is of vital importance. Cases resulting from dental 
cSiS caries can readily be remedied by treatment, possibly extraction 
of the diseased tooth. 

Rheumatic, grippal, etc., facial palsy ordinarily responds to 
local heat, the salicylates, quinine and arsenic. Pressure neuritis 
usually abates with disappearance of the tumor exerting the 
pressure upon the nerve. Facial palsy occurring in connection 
parafysff with parotitis calls for no special treatment. Where the pressure 
is due to a new growth, enucleation of the latter should promptly 
be undertaken. Recovery is not as rapid in the latter form as in 
the other varieties. 

After abatement of the hyperacute symptoms a weak galvanic 
current should be applied four to six times a week, for from two 
to three minutes at a time. The anode should be held behind the 
ear, while the different facial nerve branches and muscles are 
stroked with the cathode. 

It has been observed that recovery is assured — after a shorter 
■^issured or longer period of time — in all cases of facial paralysis in which 
Teturn^of ^^c elcctric reaction remains normal from the start or returns to 
re^actioi'? normal after a lapse of from one to two weeks. On the other 
hand, cases which present complete reaction of degeneration of 
nerve and muscles after that period of time usually offer a doubt- 
ful prognosis. Protracted cases may lead to degeneration and 
shortening of the affected muscles, so that the face appears drawn 
to the paralyzed side. 
Differentia- Peripheral facial paralysis should not be mistaken for central 

tion from ^ . . , t- 

eerebrai or nuclear facial palsy. In cerchral palsy the muscles of the 
nuclear forehead and eyes, for the most part, escape (i.e., the patient is 

T)3r3lvsis 

able to frown and to close the eye on the affected side) ; the elec- 



POLYNEURITIS. 543 

trie reaction is retained ; furthermore, the palsy is frequently asso- 
ciated with hemiplegia of the same side. In nuclear or basilar 
paralysis the palsy is usually limited to the lower half of the 
face (from the mouth dow^n) and is complicated by other symp- 
toms indicating a lesion in the pons, such as crossed paralysis and 
disturbed action of other cranial nerves. 



POLYNEURITIS 

(Multiple Neuritis). 

Polyneuritis is an inflammatory, degenerative affection of the 
peripheral nerves. In severe cases the lesion ascends to the nerve 
trunks or even the roots. Its distribution is almost always Bilateral 
bilateral and symmetrical. Polyneuritis is very rarely observed metrical. 
in children, since the principal causes of the affection — alcohol-, 
lead- and arsenic-poisoning — are of exceptional occurrence in 
young children. The most frequent form of polyneuritis en- 
countered is that described as "Diphtheritic Paresis." (See 
"Diphtheria.") 

The onset of multiple neuritis is usually fairly rapid with 
numbness, pricking, pain and chilliness of the parts to be affected. ^. 
This is followed by the appearance of motor inco-ordination pai^ and 

-^ -^^ motor mco- 

( ataxia) up to paralysis of symmetrical groups of muscles {e.g., ordination. 
of the hands and feet) or of entire extremities. The lower 
extremities are ordinarily affected first and the upper later. 
Genuine foot- and wrist-drop are rare exceptions. The same is 
true of involvement of the muscles of the trunk, and the sphinc- 
ters. The motor symptoms are usually associated with sensory 
disturbances — pain, especially on pressure, along the nerve trunks, 
hyperesthesia and more rarely anesthesia. The electric and 
tendon reactions are diminished, and reaction of degeneration is 
quite common in severe cases. With early treatment — elimina- 
tion of the poison (sodium iodid, magnesium sulphate, in lead 
poisoning), mitigation of pain (salicylates, warm baths), tonics 
(strychnine, iron, etc.), and galvanic electricity and massage — 
the prognosis is usually favorable, except when the respiratory 
muscles are affected. Occasionally atrophy, with consecutive Atrophy 
contractures and deformities, may persist for a long time, and contractures, 
even for life. 



544 



DISEASES OF THE NERVE SYSTEM. 
Differential Diagnosis. 





Polyneuritis. 


Poliomyelitis • 


Landry's Disease. 


Onset 


Usually slow. Sligfht fe- 
ver, if any. 

Symmetrical. Partial. 
Lower than upper ex- 
tremities. Exception- 
ally other parts of 
body. 

Persistent. 
Present (partial). 

Late. 

As a rule, gfradual recov- 
ery. 


Quite acute ; often 
vomiting:. Moder- 
ate fever. 

Irregular. Complete; 
often only one limb, 
or a group of mus- 
cles, e. g., neck. 

Transient. 
Absent. 

Early. 

Partial, spontaneous, 
recovery. 




Distribution of par- 
alysis 


(pain); no fever. 
At first asymmetrical. 


Hyperesthesia 

Anesthesia 

Atrophy and de- 
formities 


Ascending. Com- 
plete. Legs, trunk, 
arms, and muscles 
innervated from the 
medulla. 

Variable, 

Absent. 

Very late, if at all. 


Termination 


Usually fatal within 
two weeks. Excep- 
tionally, recovery. 



Differentia- 
tion from 

hereditary ataxia 
ataxia and 
myelitis. 



The history of the case is very helpful in the diagnosis. Thus, 
in multiple neuritis, we are often able to elicit a history of some 
form of toxemia (infectious disease; lead-, arsenic-, or alcohol- 
poisoning) ; in poliomyelitis its prevalence in epidemic form may 
be decisive. 

Polyneuritis may occasionally be mistaken for hereditary 
very slow in development, involvement of cranial nerves ; 
mental debility; and myelitis — sphincters invariably involved. 



HEMIATROPHIA FACIEI 

(Progressive Facial Hemiatrophy). 

The nature of this rare affection is still obscure. The path- 
ologic findings point to an interstitial inflammatory process of 
the trigeminus. It occurs in girls more frequently than in boys, 
on the left side more than on the right, and exceptionally affects 
both sides of the face. 
Begins at It begins with a small part of the face (usually over the fossa 
canina. caniua) tumino- white, thin, wrinkled, etc. From here the 

Atrophy of ^ ^ 

muscles atroohv rapidlv spreads to the muscles and bones of the entire 

and bones. ^ •' r- j r 

half of the face, including the hair. At times the atrophy spreads 
to the chest and other parts of the body, but finally reaches a 
permanently quiescent stage. Sometimes there are also anomaHes 
of pigment. It is occasionally associated with scleroderma and 
exophthalmic goiter. 

Sensation remains intact and the electric reactions are normal. 
The cause of the atrophy being unknown, the treatment must, 
necessarily, be symptomatic. Paraffin injections have proved 
very useful to correct the remaining facial deformity. 



Family 



MUSCULAR ATROPHIES. 545 

HEREDITARY PROGRESSIVE MUSCULAR 
ATROPHIES 

(1. Spinal. 2. Neural. 3. Myogenic). 

This classification is intended solely to emphasize the prin- 
cipal locations of the underlying lesions. The disease is trans- ^^i^ease. 
mitted from generation to generation and often affects several 
members of the same family. 

1. SPINAL PROGRESSIVE MUSCULAR ATROPHY. 

It is observed in early infancy. It begins with weakness of 
the muscles of the legs, back, neck, throat, shoulders, arms, hands, fhT£|sT^^^ 
fingers and toes. As the disease advances the muscles are com- over^bocfy.^ 
pletely atrophied (rarely pseudohypertrophied) so that the child 
is entirely helpless. The reflexes are abolished and the electric 
reactions greatly disturbed. The disease ends fatally within 
about four years from involvement of the respiratory muscles and 
consecutive pneumonia. The lesion consists of atrophy of the 
cells of the anterior cornu of the entire spinal cord and degenera- 
tion of the motor nerve fibers. There is no central involvement; 
hence, no cerebral symptoms. The sphincters are intact. Fibril- 
lar twitching is infrequent. 

2. NEURAL PROGRESSIVE MUSCULAR ATROPHY 

(Peroneal Type). 

It is characterized by atrophy beginning with the muscles of 
the legs, especially the peroneal group, and by predominance of ^groneaf ^^ 
sensory disturbances, hyperesthesia or anesthesia. In walking g"°JPigg^ 
the child lifts the feet high and touches the floor with the tips. J^'^f^^g'''''^^^^ 
If the muscles of the hands are affected the hand becomes claw- 
shaped. Occasionally other muscles are implicated. The patel- 
lar- and Achilles'-tendon reflexes are at first diminished and later 
abolished. The electric reaction of the atrophied muscles varies 
— is normal in some cases, disturbed in others — irrespective of the 
state of the atrophy. Fibrillar twitchings are common. The ^^t'jhfngs. 
course of the disease is very slow and interrupted by remissions 
of variable length, and judging by the underlying pathologic 
anatomy of the affection (degeneration of the respective per- 
ipheral nerves, with slight implication of the spinal cord) it is 
per se probably not fatal. Massage, baths and electricity are of 
benefit. 

35 



546 DISEASES OF THE XERVE SYSTEM. 




Fig-, i; 



MUSCULAR ATROPHIES. .347 

3. MYOGENIC PROGRESSIVE MUSCULAR ATROPHY 
(Dystrophia Muscularis: Pieudohypsrtrcphic Paralysis). 

Under this heading are grouped the foiiownig four morbid 
conditions which were formerly looked upon as distinct path- 
ologic entities : — 



Fi^s. 176, 177 and L'S. — Pseudoh^-pertrophic Paralysis. Dem- 
ons:-?.:: :. i-f mode of rising from the j^oor by "climbing upon him- 
self." S'-.cf.eld:^ 

,j, Simple Hereditary' Muscular Atrophy. — It usually 
attacks children betwee:: ;:i^i:: ?: ;. :c:: years of age, and is mani- ^5^^^,^^ 
tested by weakness and atrophy of the muscles of the back (with- ^^^.j^ 
out pseudohypertrophy j , lordosis and paresis. 



548 DISEASES OF THE NERVE SYSTEM. 

(b) Infantile Muscular Atrophy — Facioscapulohumeral 
In early Type (Landouzy-Dejerine) . — As the name indicates it begins 
in ancy. .^ g^j-jy infancy with atrophy of the face, especially the orbicu- 
laris oculorum and oris and the lips. The patient is unable to 

Affects . ' . 

face, close the eyes, to point the mouth, and his face becomes expres- 
sionless, like a mask. Pseudohypertrophy of the facial muscles 
sets in later, so also the atrophy of the muscles of the scapulo- 
humeral regions. 

(c) Juvenile Muscular Atrophy (Erb). — The atrophy is 
Muscles manifested, at a later age than in the former variety, in the 

and back, following order : The pectorals, the anterior serrati, the latissi- 
mus dorsi, the rhomboidei, and the trapezius muscles, and then 
the triceps, biceps, brachioradial and brachial muscles. The del- 
toid is usually strongly hypertrophied. 

(d) Pseudohypertrophy (Duchenne). — In this form of the 
calves of disease the muscles first affected are those of the calves, the 

'spinal extensors of the thig^h which become srreatly enlarg-ed, and then 

muscles. ,. ., ° aii- 1111 

the long spinal muscles. As the disease progresses the shoulder, 
arm and lumbar muscles become involved, the deltoid, supra- and 
infra-spinati showing an especial tendency to pseudohypertrophy. 
The forearm and hands remain free. Owing to weakness of 
"Saddle- the crector spinse and glutei muscles, the patient keeps his trunk 
waddling tlirowii backward, ''saddle-back," and walks with a peculiar 

gait. ... . 

waddling gait, with the legs widely separated and the toes barely 
touching the ground. The gait at times resembles that of bilateral 
dislocation of the hip. If placed on the floor, the efforts made to 
rise are very characteristic. Awkwardly and with difficulty he 
^ ^ places first one hand and then the other on the legs, then on the 

Climbs ^ . . . 

upon thig^hs above the knees and in this manner he "climbs upon him- 

himself. *^ . . . . ^ 

self" until he assumes the erect position (see Figs. 176, 177, 1/8). 
In time, the patient becomes unable even to sit up. 

The distinction between the different forms of myogenic 
dystrophia cannot always be made with exactness, as the order 
with which the atrophy begins is not rarely reversed. All 
varieties of the affection at a late stage present diminution of 
the tendon and electric reactions — but no reaction of degeneration 
or central disturbance. Fibrillary twitching of the atrophied 
muscles is absent and local vasomotor disturbances are rare. As 
the disease advances and the paralyzed muscles contract, various 
deformities (spinal curvature, talipes, etc.) make their gradual 
appearance and render the patient totally helpless and bedridden. 



EPILEPSIA. 



549 



The course of the disease is slow, and occasionally inter- 
rupted by remissions of variable length, and temporary improve- 
ment. Death usually takes place within ten years from the onset 
of the affection, as a rule, from intercurrent diseases, especially 
pneumonia. Treatment, in the form of baths, massage, etc., may 
prove effective to check the progress of the manifestations, but it 
is doubtful that it ever leads to permanent recovery. 

The disease is attributed to an extraordinary increase of con- 
nective and adipose tissues with corresponding atrophy and 
gradual disappearance of fibers of certain muscles. Slight lesions 
are not rarely found also in the cord. The etiology is obscure. 
The absence of fibrillar twitching and of atrophy of the hands 
and forearms serve as differential points from "Spinal Pro- 
gressive Muscular Atrophy." (See page 545.) 



Slow 
course, 
with 
remissions. 



Lesions also 
in cord. 



moving 
certain 
muscles. 



MYOTONIA CONGENITA 

(Thomsen's Disease). 

It is a rare, probably hereditary affection of the muscular 
system, characterized b}^ sudden spasm and rigidity of individual Rigidity on 
or groups of muscles, especially when the patient begins a volun- 
tary movement, e.g., arising from a certain posture, clasping 
hands, etc. Similar tonic contractions occur from the effects of 
a blow upon a muscle; and the application of a strong (20 to 25 
milliamperes) galvanic current produces certain wave-like mus- wave-iike 
cle contractions which move from the area of the cathode to that contractions. 
of the anode. Although often appearing already in early infancy 
the disease does not endanger life or health. Warm baths and 
massage may prove of benefit. 



EPILEPSIA 

(Epilepsy; Fits). 

Epilepsy is an obscure affection of the brain, in typical form 
characterized by attacks of loss of consciousness, local or general 
convulsions, and a great tendency toward psychical disturbance, p^^j^^j^ j 
The situation and exact nature of the brain lesion is still alterations 
undetermined, but, judging from the pathologic alterations 
(atrophy, hypertrophy, abscess formation, sclerosis, porenceph- 
alia, retention of subcortical cells, changes in the blood, etc.) so 
frequently found post mortem, there is reason to believe that 



in the 
brain. 



550 DISEASES OF THE NERVE SYSTEM. 

there is no one pathologic entity responsible for the morbid 
condition. 

The causes of epilepsy are many and diverse. Congenital 

Traumatism. ■, r ^ r.ii- in "^- ,,. ,,, 

detects of the bram or skull; traumatism to the bram or skull 
(during birth or after) ; infectious diseases afifecting the brain 
directly or indirectly; toxemias of all kinds, including grave 
Toxemia, gastrointestinal intoxication ; repeated attacks of convulsions from 
reflex causes ; neoplasms, including syphilitic and tuberculous ; 
sudden psychic disturbances, such as sudden shock, etc., among 
many other as yet obscure causes, all contribute their share 
toward the development of epilepsy at some period of life. An 
Hereditary herccHtary disposition is traceable in a certain number of cases, 

eucum- . 

brances. and children of syphilitic, alcoholic, and neurotic parents are 
more prone to contract the affection than those free from such 
encumbrances. 

No age is exempt from the disease, but it is most apt to 
develop in children of from two to fifteen 3^ears old. 

The exact time of beginning of the disease cannot always 
be traced, since the symptoms may be so mild as to escape obser- 

Rudimentary _ \ . . . ,, 

forms, vation. The child may for a few moments "hang its head," turn 
pale, and the paroxysm would be over with — hardly any reason to 
suspect epilepsy. The little attack may not recur for weeks or 
months, so that the last one is long forgotten when the next one 
sets in. It is only after the attacks grow longer in duration, 
stronger, more frequent, are preceded by an aura and possibly 
followed by involuntary urination and defecation, and profound 
sleep, that the nature of the dreadful condition is fully realized. 

Genuine epilepsy varies greatly in severity not only in differ- 
ent individuals but also at different times. In addition to the 
rudimentary forms later to be described, the paroxysms are gen- 
erally classified into severe (graiid mal), mild (petit mal), and 
cortical or Jacksonian. The attacks are frequently preceded by a 
Aura, warning (aura) of motor, sensory or vasomotor character. 
There may be slight twitchings of the limbs, eyes, or head ; slight 
general tremor, a vague sensation in the stomach, a feeling of 
numbness or pricking in the extremities, hearing of noises, seeing 
of colors or sparks, smelling of peculiar odors, irritability, 
hallucinations, etc. 
Grand Dial ^^ grand mal immediately following the aura, and also with- 

out it, the patient, who may appear to be in good health, suddenly 
loses consciousness and falls, and becomes fixed in a tonic spasm, 



EPILEPSIA. 551 

with face and limbs contorted and breathing suspended. His 
face is pale or cyanotic; his eyes are widely open and staring or 
rolled upward or sideward. The teeth are pressed firmly 
together, with the tongue often impacted between them. In a 
moment the fixed spasm gives way to clonic convulsions. The Tonic and 
face, body and extremities twitch violently, and the head beats com'uisions. 
strongly backward. During this stage the face is congested 
and often bathed in perspiration. Foam frequently fills the 
mouth, and may be mixed with blood from the severely bitten 
tongue. As the contractions cease, the child sinks down ex- 
hausted, limp and lifeless — except for deep sighing respiration — 
into a state of profound sleep (postepileptic coma) of variable 
duration. With return of consciousness he has no knowledge of 
what occurred. The duration of the paroxysms varies between 
one and five minutes. It may occur once or several times a day, 
a w^eek or month, or may not return for several months and even 
years. A certain periodicity, however, is demonstrable in a great 
many cases. The attacks may also occur at night, during sound 
sleep. 

Petit mal is usually manifested by sudden loss of conscious- peut mai. 
ness of very short duration. The patient may turn pale, stare 
vacantly, twdtch a little, drop what he is holding, and then recover 
himself. Often in the midst of play the child suddenly stands 
fixed, "as if bewdtched," with staring, absent-minded expression ; 
a few moments later he resumes his play as though nothing had 
happened, or sinks down feebly or runs toward some object or 
person to support himself. The transition (sometimes after 
jxars) of petit mal into grand mal is not rare, and should ahvays 
be remembered in fixing the duration of epilepsy. 

In another group of cases the convulsions begin in one par- 
ticular muscle or group of muscles, and rapidly spreads to other 
parts of the body. Loss of consciousness may be absent or occur 
after the convulsions have become general. It is often followed 
bv localized paresis. This cortical or Jacksonian form of epilepsy 

^ , . . i. i- ^ Jacksonian. 

is based upon a definite local lesion in the cortex. 

Epilepsy is not always represented by so typical a clinical 
picture. Rudimentary forms are encountered, wdiich may tax 
the skill of even the best observer in reaching a correct conclusion. 
Two forms deserve special mention : Epilepsia nutans, and 
epilepsia procursiva. 

Epilepsia nutans (''Salaamkrampf") is manifested by sud- 



552 DISEASES OF THE NERVE SYSTEM. 

^^foSJSd ^^^ lightning-like spasmodic forward movementsi (between 
movements. 20 and 100) of the Upper part of the body— a sort of reverential 
bow — and is associated with partial or complete loss of con- 
sciousness. 
Sudden Epilepsia procursiva is characterized by a sudden forced 
runn^nl^ Start of running, of variable duration, which may cease abruptly 
or end in an attack of convulsions. Consciousness is partially 
lost during this seizure. 

In children as in adults, instead of typical or atypical attacks 
of morbid physical phenomena, momentary states of mental dis- 
^fits. turbances may occur which may vary from simple confusion up 
to acute mania. These fits occasionally alternate with convulsive 
seizures. Less frequently than in adults are the so-called post- 
^°^*^' attacks^ epileptic — frequently rather proepileptic psychical aberrations 
which are manifested by unconscious, automatic, more or less 
violent actions, lasting minutes, hours or days. Inexplicable dis- 
appearance of children from home is not rarely an epileptic 
manifestation. 

Epilepsy sooner or later leads to permanent mental impair- 

effects. ment. In the earlier stages this may consist only of weakness of 

memory, silliness, alteration in the behavior (the child may be 

cranky, quarrelsome, destructive, etc.), but as the disease becomes 

chronic the patient's mental dullness increases and may reach a 

state of total idiocy. Furthermore, with the growing mental 

hebetude there is also a corresponding development of coarse 

features with a downcast, dazed, and stolid expression — physical 

peculiarities which to the keen observer often betray some 

hidden central lesion. This observation often serves well in the 

differential diagnosis between epilepsy and reflex and hysteroid 

convulsive paroxysms. (See ''Spasmophilia" and "Hysteria.") 

The termination of epilepsy is subject to great variations. 

Prognosis With the recent e^radual improvement in the methods of diae^nosis 

favorable ^ ^ . . ? . 

under and treatment, complete recovery from genume epilepsy is far 
treatment, from being exceptional. This refers particularly to cases due to 
reflex causes (defective vision, adenoids, worms, phimosis, etc.), 
when early detected and remedied. To a great extent this is true 
also of cases resulting from traumatism or benign neoplasms, 
which are nowadays operated upon more or less successfully. 
The surgical results are especially gratifying in the Jacksonian 



1 Similar forward movements are frequently observed in divers forms 
of idiocy. 



EPILEPSIA. 553 

form of epilepsy. Operative interference, however, should 
always be preceded by an antisyphilitic course of treatment, 
which not rarely acts admirably. Some cases of epilepsy, after 
resisting all sorts of "cures" for a number of years, get well as 
unexpectedly as they got sick. Others again persist for life, do 
what you may. This is the so-called idiopathic epilepsy for 
which from time immemorial the whole pharmacopeia, witch- 
craft, mental healing. Christian or unchristian Science, etc., have 
been used in vain. What can be accomplished, however, in such 
cases is the lessening of the severity and frequency of the attacks. 
All sources of irritation, however trifling, should be removed. 
The patient should be placed on a light, salt-free diet, under the 
best possible hygienic conditions, and in the most congenial and 
restful surroundings. Residence in the country, with plenty of 
outdoor air, moderate exercise and hydrotherapy are ideal 
adjuvants. 

Immediate attention should be paid also to the convulsive fit, 
not alone to prevent a fatal issue from cerebral hemorrhage, or 
possibly from apnea, but principally to avoid grave bodily injury 
which the patient is apt to sustain during a severe fit. When the 
attacks are of frequent occurrence the child should not be left 
alone, especially in a room wnth an open fire, or in the vicinity of 
ponds, rivers, railroad tracks, etc., lest he be suffocated, fall out 
of bed, set himself on fire, drown, etc. A handkerchief or cork 
should be placed between the upper and lower molars to prevent 
biting of the tongue. A severe convulsive seizure may be aborted 
or modified by a few whiffs of chloroform, or amyl nitrite. 

Of all remedies thus far recommended the bromids are the 

only ones which have proved of actual benefit in all forms of 

epilepsy. We should begin with moderate doses that will control 

the paroxysms. The bromids may advantageously be combined 

with small doses of Fowler's solution of arsenic. The treatment 

should be continued, with brief intermissions, to avoid bromism, 

for years — long after cessation of the attacks. 

IJ Natrii bromidi, 

Ammonii bromidi aa 3ij | 8 

Strontii bromidi ^j j 4 

Liquor potassii arsenitis 3ss | 2 

Mist, rhei et sodae Sss | 15 

Syr. aurantii q. s. ad fS.iij | 90 

M. Sig. : 3j in water every six hours, and later only twice a day, for 
a child 6 years old. 

In severe fits we may add small doses of codeine. 



Reduction 
of attacks. 



Attention 
to fit. 



Bromids. 



554 DISEASES OF THE NERVE SYSTEM. 

When the bromids are not well tolerated by the stomach they 
may temporarily be administered per rectum. Postepileptic out- 
breaks frequently yield to early administration of hypnotics, espe- 
cially chlorq^l. 

FUNCTIONAL SPASMODIC AFFECTIONS. 

SPASMOPHILIA. 

Eclampsia Infantum; Tetanism; Tetany; Pseudotetanus ; 
Spasmus Glottidis. 

The subject in question is of great clinical importance, and 
still shrouded in mystery. Spasmodic affections are generally 
attributed to a number of local bodily irritations which act 
reflexly upon the central nerve system. We know this to be true. 
We know also that the infantile brain is very vascular, very irri- 
table, very impressionable, lacking in power of resistance and 
control. We are in the dark, however, as to why the very same 
etiologic factors are prone to produce mild or severe convulsions 
in one child and none at all in the other. This apparent dis- 
crepancy in action leads one to assume that some children are 
born with a marked tendency to spasmodic affections. This, 
probably hereditary, spasmodic tendency ("spasmophilia") is dis- 
to spasms, tinctly traceable in children of nervous, alcoholic, syphilitic or 
tuberculous parentage, and exerts its influence principally on the 
group of functional spasmodic affections presently to be described. 

1. ECLAMPSIA INFANTUM 
(Convulsions), 

Non-epileptic convulsions are of common occurrence in 

children, especially in infants under one year of age. They may 

occur as a partial phenomenon of all sorts of acute systemic dis- 

Toxemia. turbanccs, e.g., toxemia from infectious diseases ; gastrointestinal 

intoxication ; shock, and trauma ; or in consequence of continued 

Reflex . . , . . ... . , 

irritations, rcflcx imtatious, such as phmiosis, adenoids, mtestmal worms, 
intense pain from various causes, earache, teething, calculi, 
and the like. The frequency of the convulsive seizures is within 
no definite limits — from one attack in several months up to as 
many as thirty or more attacks in a day. The convulsions are 
both tonic and clonic in character. In the beginning the body is 
more or less rigid, the head and neck are retracted, the eyeballs 
are turned upward or roll spasmodically in different directions. 



Inherited 
disposition 



FUNCTIONAL SPASMODIC AFFECTIONS. 



ooo 



The face is distorted and grows cyanotic as breathing becomes 
labored or temporarily ceases. These tonic spasms are soon Tonic and 
replaced by clonic convulsions — irregular and rapid twitching of spasms, 
the extremities and face or of single groups of muscles — which 
may last from a few seconds to several minutes, may remit and 
return with greater violence. With complete cessation of the 
convulsions the patient usually falls asleep, to wake up apparently 
free from cerebral disturbance. During the attack consciousness conscious- 
is lost. Occasionally there is loss of sensation as well as involun- 
tary urination and defecation, foaming from the mouth and biting 
of the tongue — a group of symptoms which are generally met in 
epilepsy. This, together with the fact that eclampsia is not rarely 
a precursor of genuine epilepsy should put the physician on his to epilepsy, 
guard in venturing a positive view as to the nature and curability 
of the spasmodic affection. 

Epilepsy differs from eclampsia in that the fit is preceded bv 

" . . . , , . , . , , .' Differential 

an aura, that it is oi short duration but non-remittent, and that it diagnosis 

is invariably followed by profound sleep — not the light sleep genuine 

which follows eclampsia. We should bear in mind, however, that uremia and 

these differential signs are much less reliable in epilepsy of localized 

C6r6br3.1 

children than in adults. disease. 

Eclampsia infantum is to be carefully distinguished from 
uremic convulsions, and spasms accompanying brain disease. In 
uremia there is usually a history (scarlatina?) of suppression of 
urine. The latter reveals evidences of kidney disease. Cerebral 
convulsions are associated with projectile vomiting, possibly a 
history of trauma, tuberculosis, otic abscess, and the like. The 
convulsions of organic brain disease are apt to be more localized, 
and be followed by paralytic phenomena. 

When called upon to treat a child in an attack of convulsions, 

...... . . Arrest of 

the physician is rarely m position to make exact and scientific spasm, 
discriminations between the different forms of convulsions. It 
is essential to arrest the convulsions irrespective of cause or effect, 
since a prolonged attack may end fatally from exhaustion or 
suffocation. The spasms are best controlled by means of 
chloroform inhaled from a handkerchief, moistened with ^ to 1 
teaspoonful of the anesthetic. The anesthetic may be continued 
at long intervals for hours or days without endangering the life 
of the patient. As the convulsions subside, we begin to make 
careful inquiry into their causation and to employ the therapeutic 
measures indicated in each individual case. Hyperpyrexia calls 



556 



DISEASES OF THE NERVE SYSTEM. 



Symptomatic 
treatment. 



for hydrotherapy (cold sponge or tub bath) ; gastroenteric dis- 
orders, for emesis (apomorphine Y^q grain hypodermatically, or 
ipecac by mouth), catharsis (2 grains of calomel in one dose) and 
enteroclysis ; intestinal worms, for teniafuges (turpentine inhala- 
tion, and calomel and santonin by mouth) ; nervous disturbance, 
for hot baths with or without mustard, bromids and chloral per 
rectum or by mouth, and counterirritation in the form of a mus- 





^ \ 


A 





Fig. 179. — Tetanism. (See page 558.) During acme of spasm. 
(Sheffield.) 



Prophylaxis. 



tard plaster or mustard-water cloths applied to the spine from the 
nucha downward. Lumbar puncture is a sovereign remedy in all 
forms of cerebral irritation associated with increased intracranial 
or intraspinal pressure and with the usual precautions can safely 
be employed in convulsions failing to yield to milder procedures. 

With cessation of the convulsions due attention should also 
be paid to the more remote etiologic factors, principally with the 
view of prophylaxis. The diet should be regulated, the general 
health improved, rachitis promptly attended to, the faulty environ- 



FUNCTIONAL SPASMODIC AFFECTIONS. 557 

ment ameliorated, local irritations {e.g., phimosis, adenoids, j^g^jo^ai 
forei2:n bodies in ear or nose, rectal fissures, intense itching etc.) 9^ .^o^,^^ 

<=> ' JO'/ irritations. 

promptly removed, and all such therapeutic measures instituted 
as will help to counteract and eradicate the inherent tendency to 
spasmodic affections. 




Fig. 180. — Tetanism. During partial relaxation of spasm. Same 
case as Fig. 179. {Sheffield.) 



^. Natrii bromidi 3j 4 

Antipyrinae 3ss 2 

Tr. ammonii valerianatis 3ij 8 

Syr. lactucarii 5iv_ 15 

Aq. aurantii flor q. s. ad f 5ij 60 

M. Sig. : 3j every three to six hours for a child two years old. (G( 
eral nerve sedative.) 



558 



DISEASES OF THE NERVE SYSTEM. 



2. TETANISM.i 

This term is intended to denote a peculiar form of more or less 

More or . . . . , . , 

less continuous muscular hypertonicity occasionally observed m mfants 



continuous. 



under three months of age. The affection is most probably due to 




Fig. 181. — Tetanism. During 
acme of spasm. Note characteris- 
tic position of extremities. (Shef- 
field.) 



Fig. 182. — Tetanism. Same case 
as Fig. 181. During partial re- 
laxation of spasm. (Sheffield.) 



gastrointestinal intoxication, since the infants suffering from it 
almost invariably are bottle fed, greatly reduced in vitality (often 
premature or syphilitic), subject to gastrointestinal derangement 

1 A similar or the same affection has been described by Hochsinger 
as "myotonia of the newly born and nursling." This designation is very 
misleading in view of its resemblance to "myotonia congenita" (Thom- 
sen), which is an entirely different disease. 



FUXCTIOXAL SPASMODIC AFFECTIONS. 



559 



— in short present the chnical picture of profound marasmus. The 
onset of the spasmodic condition is fairly rapid. When fully estab- 
lished, the posture (see Figs. 179, 181) assumed by the infant is 
very pathognomonic. The head is retracted, the facial muscles 
are contracted, the jaws are firmly pressed together, the forearms Flexion of 

1-1^111 1-11 forearms 

are nexed upon the arms, while the hands are clmched so as to 
form closed fists. The rigidity of the lower extremities is less 



upon 
arms. 




Fig. 183. — Same case as Fig. 181. Three months later. (Sheffield.) 



pronoitnced. As a rule, the legs are bent angularly, and the feet 
either overlap each other or are strongly arched. Xow and then 
a partial relaxation of the spasm is observed (see Figs. 180, 182j, 
and the spasm ceases entirely during sound sleep. The hyper- 
tonicity increases on handling the baby, but the "triad of tetany" 
is absent. The child is able to nurse without difficulty, in these 
respects differing from genuine tetanus and eclampsia. 

AATth improvement in the general condition the spasticity 
gradually (within a week or a month or longer) subsides. Few 
babies survive, however, the persistent gastroenteritis and increas- 
ing exhaustion. The treatment is the same as in tetany, except 



Differentia- 
tion from 
tetany, 
tetanus anc 
eclampsia. 



560 DISEASES OF THE NERVE SYSTEM. 

that there is seldom an indication for the employment of 
hypnotics. 

3. TETANY. 

cSftra^tur^e^* ^^'^^ discasc is characterized by intermittent somewhat pain- 
ful contraction of certain groups of muscles, especially of the 
extremities, with exaggeration of the mechanical and electric 

and^sudden^ irritability. The spasm is bilateral and usually sets in abruptly 
without loss of consciousness. The hands assume a very peculiar 
shape greatly resembling that of holding a pen or of an obstet- 
rician dilating a tense cervix uteri (main d' accoucheur). Thus, 
'^Snd^ the fingers are flexed upon the palms, the phalanges are extended, 
the thumbs are turned inward so as to be covered by the other 
fingers, and the wrists are flexed in pronation. When the lower 
extremities are affected the legs are adducted and the plantar 
surfaces of the feet are strongly arched, with a tendency to an 
equinovarus position. Occasionally the tetanic spasm extends 
to the neck and back, and exceptionally also to the laryngeal and 
^foYm. other muscles of the body. On the other hand, cases of tetany 
are encountered in which the spasms are entirely wanting or 
barely indicated. These "latent" or passive forms of tetany may 
frequently be brought into activity by energetic pressure upon the 
, main trunks of the nerves or vessels. This peculiar mechanical 

Trousseau s -^ 

sis^- manifestation is spoken of as 'Trousseau's phenomenon," and 
forms one of the three positive signs of tetany — the so-called 

chvostek's "^'^'^^^ ^^ tetany." The other two signs of tetany are those of 
phenomenon. Qivostek and Erb. ''Chvostek's phenomenon" is based upon 
exaggeration of the mechanical irritability of the motor nerves, 
especially of the face (facialis phenomenon), and consists of 
lightning-like contractions of the face superinduced by percussion 
(with the finger or hammer) over a branch of the facial nerve 

Erb's sign, ^^^iie the face is in a state of perfect rest. "Erb's phenomenon" 
is based upon electric excitability of the motor nerves, so that 
a very slight electric current produces KaSzi or even KaSTe, if 
the current is but slightly increased. Sometimes AnOeTe and 
KaOeTe are obtained. 

The duration of the tetanic attack varies from a few minutes 
to several hours or longer, and may recur once or several times 
daily or but once in several days. In the great majority of cases 
the disease usually subsides within a few days or a month or 



1 Ka stands for cathode ; An, for anode ; S, for closing ; Oe, for open- 
ing; z, for weak contracture; Te, for tetanic contraction. 



FUNCTIONAL SPASMODIC AFFECTIONS. 



561 



two, without any permanent sequelae, provided suitable treatment 
is instituted early. The treatment, especially with the view of 
prophylaxis, is essentially the same as employed in rachitis — cor- Related 
responding to the apparent relationship that exists between the *° tickets, 
pathogenesis of rickets and that of tetany. Like rickets, tetany 




Fig. 184. — Tetany (child 11 months). Note characteristic attitude 
of hands. Slight contracture of feet. (Sheffield.) 



occurs in infants chiefly of a half to two years of age. Like 
rickets, tetany shows a predilection for poorly fed and poorly 
housed children, and finally, as in rickets, the immediate cause 
of tetany seems to be some form of intoxication, intestinal or 
otherwise. 

Whether or not the immediate cause rests upon functional or 

36 



Anti- 



562 DISEASES OF THE NERVE SYSTEM. 

organic disturbance of the thyroid gland or parathyroids is still 
subject to great differences of opinion, 
rachitic The diet should be regulated, as to quality and quantity, 
treatment. Youug infants should, if possible, receive breast milk. The intes- 
tinal tract should be cleansed with calomel by mouth, lavage and 
high enemas. For the relief of severe contractions prolonged 
warm baths, bromids and chloral, will usually prove efficient. 
(See also "Rachitis," page 503.) 



Differentia- 



4. PSEUDOTETANUS (ESCHERICH). 

tTon^frim This affectiou dift"ers from tetanus principally by its predilec- 

tetan^y'and ^^"^^ ^^1* ^^^ musclcs of the trunk, and by its afebrile course ; from 

tetanism. f^f^^^y ]^j {^^ Spasticity being continuous, and from tefanism by 

the fact that it attacks children of from four to fourteen years of 

age (instead of infants) who are apparently enjoying perfect 

health. The pathogenesis of the disease is still unknown. 

The patients (usually boys) suddenly complain of stiffness in 
the legs and inability to walk about. The rigidity rapidly extends 
Arms and ^o the back and head, so that the patient lies motionless like a log,, 
hands free. g-j^(>gp^ f^j. j^jg abilit}^ to make free use of his arms and hands. 
The affected muscles are maximally contracted, prominent, and 
as hard as marble. The facial muscles except those of the eyes 
also are in a state of tonic spasm, so that the facial expression is 
that of trismus, the teeth are firmly set together and barely sep- 
arable with force. Nevertheless, there is but little difficulty in 
feeding the patient. The rigidity is in partial abeyance during 
sleep as well as perfect rest, but greatly increased — up to painful 
opisthotonos, spasm of the diaphragm, etc. — by all sorts of bodily 
or mental irritations. During the height of the disease such spas- 
modic paroxysms may occur also spontaneously several times a 
day and are usually followed by profuse sweating. 
^^^^^week°'! The spasmodic condition persists without apparent variation 
for from three to six weeks, whereupon the contractures gradually 
(within from two to four weeks) abate never to return. 

The treatment is symptomatic (see "Tetany," page 558). 
Gavage, if necessary. 

5. SPASMUS GLOTTIDIS 
(Laryngospasmus) . 

Spasm of the glottis is a disease of infants of from six to 
twenty-four months old — the age in which rickets is most apt to 



CHOREA VERA. 



563 



prevail. It is closely related to and a frequent partial phenomenon 
of tetany, and seems also to rest upon the identical pathogenesis 
of the latter disorder. 

The spasmodic attack is manifested by sudden deep inspira- 
tion, dyspnea, apnea, pallor and later cyanosis of the face, fixation 
or rolling of the eyes, and more or less marked rigidity of the 
body. At the end of a few seconds breathing is resumed after 
a noisy expiration. In severe cases the spasm not rarely extends 
to the diaphragm and to the entire musculature of the body. 

The attacks usually recur at shorter or longer intervals (sev- 
eral times a day!) and, if not terminating fatally — which may 
occasionally take place very suddenly even during a simple attack 
as a result of asphyxia — gradually subside after a few weeks or 
months. In mild cases recovery is the rule. The physician 
should be guarded, however, in the prognosis. 

Spasmus glottidis can readily be distinguished from other 
forms of laryngeal stenosis by its intermittency and noiselessness. 
It should not be confounded with the momentary apnea (''hold- 
ing the breath"), frequently observed in children during a fit of 
crying. (See also ''Congenital Stridor," and "Thymus Hyper- 
trophy.") 

As the physician rarely has the opportunity to witness an 
attack of laryngospasm, his efforts must be directed chiefly 
towards its prevention. This is best accomplished by antirachitic 
treatment (q.v.), careful atention to the alimentary tract, and 
calming of the nerve irritability by means of small doses of sodium 
bromid (see "Eclampsia," page 555). Severe attacks call for 
stronger hypnotics. 

A severe attack may be aborted by dashing cold water in the 
child's face, exciting choking motions by pressure upon the root 
of the tongue, and exciting sneezing by irritating the nasal mucous 
toembrane. Timely intubation and artificial respiration have 
saved some babies from immediate death. 



Attacks of 
apnea. 



Noisy- 
expiration. 



Differentia- 
tion from 
laryngeal 
stenosis. 



Anti- 
rachitic 
treatment. 



CHOREA VERA 

(St. Vitus's Dance). 

Genuine chorea is an acute, infectious, sporadic and epidemic 
affection characterized by spontaneous, irregular movements of ^J^^^' 
the voluntary musculature, and by a special tendency toward 
cardiac complications. 



564 DISEASES OF THE NERVE SYSTEM. 

The specific causal micro-organism of this disease is still 
Related to unknown, but is probably closely related to that of rheumatic 

r euma ism. affg^^^^Qj^s, with which chorca is occasionally associated. Other 
infectious diseases (such as exanthemata), fright and mental 
overwork serve as predisposing causes. 

The onset of chorea is preceded by prodromata varying in 
duration from a few hours to a few days. They consist of fret- 
fulness, fatigue, restless sleep and occasional twitching. After 
the prodromic stage the actual attack may be precipitated abruptly 
and with full force, or come on gradually and run a mild course. 
Grotesque, The Cardinal symptoms of the disease are irregular, awkward, 
muscular iuvoluutary, muscular movements — hasty and beyond control — 
which which cease only during sound sleep. The movements inter- 
during mittcutly involve various sets of muscles, never letting up a 
moment while the patient is awake. The movements are intensi- 
fied when the patient is conscious of being observed, and tries to 
control them, or attempts to perform some voluntary action. The 
shoulders, one or both, jerk upward or downward ; the arms rotate 
from side to side, or are forcibly thrown backward or forward; 
the hands are engaged in incomplete extension, flexion, pronation 
or supination, while the fingers are bent, extended or shoved one 
over the other so that the patient is unable to hold an object firmly, 
to write, to button a garment, etc. The head sways from side to 
side, often describing a semicircle, or is dropped downward so 
that the chin touches the chest wall. The facial muscles twitch, 
and produce grotesque distortions of the face and mouth. The 
forehead is wrinkled, the eyes open and close, the patient seeming 
to cry or laugh. In one case under our observation the iris ( !) 
was involved so that the pupils contracted and dilated almost 
incessantly. The tongue participates in the movements, causing 
difficulty in eating and drinking, and defective speech up to 
aphasia. The movements of the lower extremities vary with the 
intensity of the attack, in severe cases being of such nature that 
the patient is unable to stand, sit or lie still, and frequently falls, 
stumbles, or is thrown out of bed and injured. During the acme 
of the attack it is not uncommon to find irregular respiration and 

Involvement arhythmia of the pulse — both from implication of the respiratory 
muscles and the heart (chorea cordis). Notwithstanding, how- 
ever, the intensity of the movements the patients rarely complain 
of being fatigued, in fact a great many children are otherwise in 
perfect health. The temperature is normal, the digestion good, 



CHOREA VERA. 



565 



sensory disturbances are usually rare and slight (hyperesthesia 
along the course of the nerve trunks), the patellar reflex is some- 
what exaggerated, but the cutaneous sensibility and reflexes are 
unaltered. 

If left untreated the active stage of the disease lasts from 
four to six weeks, then the symptoms gradually diminish and may 
disappear entirely a few weeks later. Some cases run a mild 
course from beginning to end, at no time presenting the afore- 
mentioned grotesque muscular excursions. This is especially 
prone to occur if treatment is begun early, and persisted in. 

The intensity of the atttack stands in no relation to its dura- 
tion; on the contrary, cases of slow development and moderate 
severity may run a chronic course and suffer relapses, while violent 
cases often respond to a few weeks' treatment. This incongruity 
is often observed also as regards complications, mild cases being 
not rarely associated with inflammation of the joints, pleura, peri- 
cardium or endocardium, whereas severe chorea may run its 
course without any untoward result. In reference to heart com- 
plications it is well to remember that not every blowing heart 
sound heard in chorea is indicative of a valvular lesion — the 
majority of these adventitious sounds disappear, perhaps, never 
to return. On the other hand, heart lesions have been found at 
the autopsy without any indications of their presence during life, 
a fact which strongly emphasizes the necessity of prophylactic 
measures being taken against heart disease (perfect rest) during 
the active stage of the disease. 

Sometimes the muscular disturbance is limited to one-half of 
the body {hemichorea), showing that the lesion is localized in 
one hemisphere of the brain. This form of chorea is more serious 
than bilateral chorea. It is often associated with paresis of the 
extremities, one or both {chorea paralytica; chorea mollis), and 
changes in the psychical condition, e.g., melancholy, hallucina- 
tions. 

Notwithstanding the grave nature of the affection the prog- 
nosis of chorea, on the whole, is favorable. A fatal termination 
is exceptional. It may occur either as a result of complicating 
heart disease, or from some, as yet unknown, effect upon the 
central nerve-system. To the latter class belong the cases asso- 
ciated with delirium and prostration. On the other hand, the 
prognosis as to permanent recovery is not quite promising. 
Recurrences are frequent, and as previously mentioned the tend- 
ency to permanent heart disease great. 



Self-limited. 



Complica- 
tions. 



Hemictiorea. 



Paralysis. 



Recurrence. 



566 DISEASES OF THE NERVE SYSTEM. 

With these facts in view, the urgency of instituting preventive 
measures against chorea is obvious. This is strongly empha- 
Epidemicity. gized by the observation that chorea may appear in epidemic form 
(it is quite common to find several members of one family to be 
Pseudo- attacked simultaneously or within a brief period of time). I am 
chorea. ^^^ referring to the hysterical ''pseudochorea" not rarely encoun- 
tered in epidemic form in girl's boarding-schools (see ''Hysteria," 
page 588). Prophylaxis is best accomplished by isolation of 
the patient. This is imperative in hospitals, asylums or private 
schools where several inmates are congregated in close quarters. 
Girls (between 6 and 12 years of age) particularly should be 
kept apart, as they are very susceptible to chorea — about 70 per 
cent, of the cases being met in girls. 

The active treatment consists principally of perfect rest in 
Physical bed in an airy and sunn}^ room, and avoidance of all mental excite- 
rest. ment. While the choreic movements are very pronounced, the 
patient should be kept in a well-padded bed (to avoid injury) 
day and night, but, as the symptoms improve, she may be allowed 
to sit up or be around and about for a few hours at a time. A 
therapy, warm bath with a cool sponge once or twice a day and a daily 
colon flushing are very salubrious. The food should be bland, 
nutritious, and preferably Hquid or semisolid (milk, cereals, 
broths, fruit- juice, etc.), especially when mastication and deglu- 
tition are difficult. Arsenic in the form of Fowler's solution is 

Arsenic in n ■ ■,■, r ■, i 

large the remedy par excellence m all cases of chorea, except when 
associated with marked paresis. It should be begun with in 
^-drop doses for every year of the child's age, and increased by 
y2 a drop every other day. Should the urine show the presence 
of albumin, the lids become puffy, the stomach irritable (pain or 
nausea), it is advisable to go back to the original dose, or discon- 
tinue it entirely for a few days. In the so-called paralytic cases 
Tonics, general tonics should be given instead of the arsenic, and in cases 
with rheumatic or cardiac complications moderate doses of any 

Salicylates of the salicylate preparations, with or without the infusion of 
digitalis, digitalis — according to indications. During the acme of the dis- 
ease, the bromids with chloral or a similar hypnotic will be 
found to act kindly in reducing the choreic movements, allaying 
the nerve irritability and inducing sleep — which is so essential to 
the recovery and maintenance of the strength of the patient. In 

H n ti s ^^^y grave cases chloroform anesthesia may cautiously be resorted 
to, or lumbar puncture. Finally it is well to remember that 



SPASMUS NUTANS. 



567 



chorea is a self-limited disease, and that mild cases usually dis- 
appear without polypharmacy — under rest, good food and hydro- 
therapy. 

I^ Liq. potassii arsenitis, 

Aq. aurantii flor aa 3ij | 8 

M. Sig. : Begin with one drop for every year of the child's age, and 
increase by one drop every other day, up to full tolerance. 

H Natrii salicyl., 

Natrii bromidi aa 3iss 6 

Mist, rhei et sodse 3iv 15 

Aq. destil q. s. ad f 5ij 60 

M. Sig. : 3j every four to six hours for a child 6 years old. 

R. Ferri sulph, ex gr. x I 0.6 

Chocolate 3j | 4 

M. ft. pulv. no. XX. 

Sig. : One powder three times a day for a child 6 years old. 



HABIT SPASM. 

Children of a nervous temperament quite frequently acquire 
the habit of spasmodically moving the face (tic), fingers and 
hands, which if not immediately stopped by strict discipline is apt 
to persist for weeks and months. Habit spasm should not be 
confounded with chorea. 

A similar spasmodic condition has been described by Henoch 
as ''chorea electrica." It occurs in children from nine to fifteen, 
in the form of lightning-like spasms, especially of the neck and 
shoulders, as though produced by a galvanic current. This 
spasm seems to be identical with "paramyoclonus," but may be 
hysterical in nature. Electricity does well in these cases. 



Lightning- 
like spasms. 



SPASMUS NUTANS 
(Spasmus Rotatorius; Head Nodding). 

The disease in question is of obscure origin. It is usually 
seen in infants of from four to eighteen months of age, chiefly 
in those suffering from rachitis. The spasmodic movements are 
generally limited to the muscles innervated by cervical plexus and 
the accessory nerve, notably the recti capitis, longus colli, scaleni 
and sternocleidomastoid. In consequence of the irritation the 
head rotates from side to side or shakes anteroposteriorly at a 
variably rapid (every second) pace, with occasional interruption, 
but ceases entirely only during sleep. The head nodding is 



In infants. 



Ceases 
during 
sleep. 



568 DISEASES OF THE NERVE SYSTEM. 

usually associated with nystagmus and more rarely strabismus or 
rolling of the eyeballs. In some cases some etiologic relation 
defects, seems to exist between spasmus nutans and visual disturbance, 
but whether the defect be in the muscle or nerve supply is still 
a matter of conjecture. 

The spasmodic movements gradually disappear in the course 
of a few weeks or months, after improvement in the general 
health. 

Spasmus nutans may be confounded with "juvenile congenital 
\ion from uystagmus" (associated with marked visual defects, e.g., disease 
nystagmus." of the retina, lens, etc.) ; with brain disease (can readily be recog- 
nized by the concomitant symptoms), and epilepsia nutans (q.v.). 

MIGRAINE; HEMICRANIA 
(Sick-headache). 

Migraine is nowadays looked upon as a neurosis, closely allied 
to epilepsy. It resembles the latter in its periodicity without 
apparent or definite cause or pathologic organic basis. Cerebral 
hyperemia or anemia seems to be the immediate cause of an 
attack. The remote causes are very numerous. Gastrointestinal 
autointoxication seems to play a prominent role, and eye-strain, 
nasopharyngeal abnormalities, dental caries, helminthiasis, infec- 

tation. tious diseascs, and general debility are often found to act as pre- 
disposing causes. The disease prevails chiefly among nervous 
children over eight years of age, in girls more frequently than in 
boys. 

Like epilepsy, migraine is frequently preceded by premonitory 

epilepsy, sigus. Consisting of depression, irritability, visual disturbance, 

tremor, nausea and vomiting. The child complains of violent 

headache, usually along half of the head (hemicrania) or occiput. 

The pain is increased by jars, light, and noises, may last several 

Attack minutes, hours, or days, and frequently terminates with an attack 
omiun*^ of vomiting followed by sound sleep, from which the patient 
awakes very much refreshed and apparently perfectly well. A 
prolonged attack is not rarely accompanied by mental disturbance 
and even slight convulsions — in which event it may resemble 
organic brain disease, e.g., tuberculosis of the brain. The 
paroxysms may return after weeks, days or months ; at all events 
the disease runs a very chronic course, especially if no energetic 
efforts are made to determine the underlying cause and to 
remove it. 



Toxemia. 



Reflex 
irri 



Allied to 



treatment. 



PAYOR XOCTURXL'S. .')()<) 

AMiere the cause cannot be detected or removed, a great deal 
of benefit is usually derived from improvement of the general symptomatic 
health, especially attention to existing anemia, constipation, etc., 
and regulation of the diet. Sojourn in the country. 

During an attack the patient should be kept quiet in bed, in a 
dark, well-ventilated room. Local moist heat, and caffeine and 
quinine (in cerebral anemia), and phenacetin and ergot with 
sodium bromid (in cerebral hyperemia) are of service to relieve 
the intense pain. 

U Natrii bromidi 3j | 4 

Antipyrinas, | 

Caffeinae natrii benzoatis aa 3ss | 2 

Syr. aurantii q. s. ad f5ij 1 60 

M. Sig. : 3j every six hours for a child 6 years old. 



PAYOR NOCTURNUS 

(Night Terrors). 

Night terrors are observed chiefly in nervous children of from 
three to eight years old. Probably frightened by a horrible 
dream (seeing of ferocious animals, etc.), the child suddenly 
awakes, jumps up, sits up or leaves the bed, looks around star- 
ingly and anxiously cries or screams for help, or utters incoherent 
words. After a few minutes he recognizes those about him, quiets 
down and falls asleep. The attack may recur one or more times 
a night or at longer intervals, and ultimately disappears (some- 
times not until puberty) without serious consequences. In rare 
instances pavor nocturnus forms a precursor of epilepsy. 

As a rule, pavor nocturnus is brought about by overloading of overloaded 
the stomach before retiring, faulty feeding, hearing of fearful stomach, 
stories or seeing exciting shows ; the presence of intestinal worms, i^J^f^^mai 
adenoids and hypertrophied tonsils, and other local disturbances, 
and promptly ceases upon removal of the aforementioned causes. 
The patient should sleep in an airy, slightly illuminated room, on 
a hard matress, lightly covered and free from tightly fitting night- 
clothes. The general health should be improved by outdoor air, 
cod-liver oil, and other tonics. A moderate dose of sodium 
bromid at bedtime is useful to check frequently recurring 
attacks. 



worms. 



Congenital. 



Acquired. 



CHAPTER XV. 
Mental Diseases. 



The mental affections of childhood may be classified clin- 
ically into (1) those associated with gross and definite physical 
abnormalities, and (2) those apparently free from such defects. 
The first group in the majority of instances is due to antenatal 
disease or arrest of development especially of the nerve system, 
and, hence, is usually in full bloom at a very early age. The 
second group, as a rule, arises secondarily to traumatism or brain 
disease acquired some time after birth, develops gradually and, 
therefore, is not demonstrable until the second period of child- 
hood has been reached. 

To the first group belong the typical forms of idiocy (hydro- 
cephalic, microcephalic, amaurotic, Mongolian, syphilitic, and 
paralytic), cretinism and infantilism; the second group embraces 
imbecility, katatonia, melancholia, mania, and dementia. 

IDIOCY AND THE ALLIED MENTAL DEFICIENCIES 
(Including Cretinism and Infantilism). 

The mental faculties of an infant become appreciative with the 
Normal evolution of the senses of hearing and sight. A perfectly normal 
development, baby almost fully controls these senses by the end of the third 
month. As it grows a few months older it begins to show signs 
of power of attention, perception and memory — it is delighted 
by bright objects, recognizes familiar faces, more or less appre- 
ciates pain or pleasure, etc. When nine months old it is usually 
capable of understanding certain words spoken to it, and mani- 
fests the tendency to imitate sounds and S3dlables. At about 
one year of age, if properly trained, strong infants are in full 
control of the voluntary musculature — creeping, standing, and 
sometimes walking — and partially so of some of the body 
functions, such as defecation and urination. Premature infants 
and those of feeble vitality from other causes may acquire 
some of these faculties at a much later period of time, and yet 
grow up to be normal intellectually. However, while no standard 
(570) . . 



IDIOCY. 



571 



time limit can be set down for the establishnient of one or the 
other mental function, failure of their manifestation at an age 
considerably beyond the supposed normal period, e.g., failure of 
a child nine months old to indicate a fair possession of the power 
of attention, or to recognize persons who are in its constant 
attendance, certainly warrants the suspicion of some mental 
abnormality. 

In our effort to arrive at a correct conclusion, it is essential 
to bear in mind the unreliability of parents' views as regards 
the mental condition of their children — most parents look upon 
their offspring as the wisest in the land — and the fact that 
very sharp lines of demarcation cannot always be drawn between 
infants wath normal intelligence and those below the average. 
Hence, the importance of minute analysis of the family history 
of the patient; the past history of the patient, particularly as 
regards nerve disorders and traumatism, and the physical and 
mental conditions of the child since birth, especially as to their 
progressive or regressive character. 

A nervous heredity being traceable in the great majority of 
cases of feeble-mindedness, the family history is often very en- 
lightening in obscure conditions. Grave neuropsychopathic af- 
fections, especially if occurring in the immediate family, demand 
careful consideration, and a history of dipsomania or syphilis 
in the parents should always be looked upon with suspicion. 
Inquiry should be made about the condition of the mother 
during pregnancy. It has not rarely been demonstrated that 
infants conceived during convalesence of the mother from 
prolonged attacks of exhausting diseases {e.g., typhoid) were 
born idiots. Furthermore, serious domestic troubles, mental 
anxiety, and physical distress, extreme fright and violent 
traumatism in the mother may so disturb the normal evolution 
of the fetal organism as to create grave central disturbances 
in the offspring. Notice should be taken also of the fact that 
certain types of mental degeneracy are peculiar to certain races 
of humanity — often without any discernible cause — as, for ex- 
ample, amaurotic family idiocy in the Hebrew race. 

The association of feeble-mindedness Avith any of the afore- 
mentioned predisposing factors cannot invariably be accepted 
as proving the hereditary pathogenesis of the case in question. 
On the contrary, occasionally totally insane parents beget per- 
fectly sane children, and vice versa. Anticipation of an heredi- 



Abnormal 
mentality. 



Predisposing 
factors. 



Dipsomania 
or syphilis 
in the 
parents. 



Heredity, 



572 MENTAL DISEASES. 

tary predisposition, therefore, should not deter us from careful 
Traumatism, scrutiny of the patient's personal history, particularly as per- 
taining to traumatism sustained during birth (compression or 
fracture of the skull during tardy or instrumental delivery, etc.) 
or after, and the diseases the child suffered from up to the time 
of examination. 

No one morbid manifestation in the past history of the patient 
is as corroborative of the latter's abnormal mentality as the 
occurrence of repeated attacks of convulsions during its early 
development. Whatever the cause — be it meningitis, gastro- 
intestinal intoxication, uremia, exanthematous disease or trauma 
• — the very fact that severe convulsions occurred justifies the 
assumption of some pathologic alteration in the central nerve 
system, sufficiently grave to predispose to mental impairment. 
Whenever possible, an attempt should always be made to trace 
the exact origin of the mental deficiency. Too much stress, how- 
ever, should not be placed upon the information received. For, 
at best, histories are only guesswork, unless furnished by very 
intelligent sources — rather rarely to be expected when dealing 
with degenerates. 

Having obtained all details as to the patient's family and 
personal histories, our next, most important, work should be 
to determine the apparent mental and physical conditions of 
the child, especially with the view of comparing them with 
those of a normally developed child of the same age. 

A. Mental Stigmata of Degeneration. 

In idiots or mentally backward children the power of atten- 
^wer of ^^^^ ^^ either very poorly developed or entirely absent. They 
attention. £g^jj ^q ^^^^ noticc of their surroundings, stare vaguely into empty 
space, or move the eyes irregularly in all directions, apparently 
seeing nothing. This want of attention may be due to partial 
or total blindness of central origin without involvement of the 
eyeball, as is frequently the case in amaurotic family idiocy. 
Occasionally the patient may be subject to congenital cataract, 
microphthalmos, coloboma iridis, irideremia, lesions of the 
vitreous, strabismus, and similar visual defects which in con- 
junction with other stigmata facilitate the diagnosis. 
Defective Exccpt in enccphalitic or amaurotic family idiocy, defective 
hearing, j^g^j-jj^g Qf central origin is rather uncommon. On the other 



IDIOCY 



573 



Voracious 
appetite. 



hand, deafness is not rarely observed as a result of congenital 
malformation or acquired disease of the auditory canal. In 
the latter event a history of normal hearing at an earlier age is 
usually obtainable. 

Genuine idiocy is invariably associated with a voracious ap- 
petite, and, owing to imperfect development of the senses of 
taste and smell, no choice is manifested as to the kind of food 
given. Everything that comes along is rapidly devoured; hence 
the frequency of gastrointestinal disturbances in feeble-minded 
children. The sense of smell is sometimes so obtuse that even 
irritating odors are not productive of local or reflex phenomena 
in the respiratory tract. On the other hand, occasionally idiots, 
like animals, are endowed with a hyperacute sense of smell. 

Most idiots are insensible to touch, pain, heat or cold — anom- obtuse 

gprigpg nf 

alies of sensibility which explain the frequency with which such touch, 
children are subjected to external injuries and voluntary bodily heat' or 
mutilations. In some of them, however, especially in those with 
marked defective vision, tactile sense is so highly developed that 
by this means alone they are able to recognize persons who feed 
and care for them. 

Congenital deafness is, of course, associated with mutism. Deaf-mutism. 
But even where hearing is intact, few idiots are able to speak. 
Some of them, by imitation, do learn to utter a few words, 
but their expressions usually bear no relation to any distinct 
desire or action, and they understand words spoken to them no 
better than what they speak. Moreover, their power of imitation 
is very much delayed in development or may never become mani- 
fest — all depending upon their poor faculty of attention. In 
partial idiocy, such as mild forms of infantilism, cretinism, 
encephalitis, or microcephalus, the power of conversation may 
reach a certain degree of potency, but their vocabulary is usually 
very limited and fragmentary. 

This form of pseudo-de3ii-inutism, like genuine deaf-mutism, 
is not necessarily indicative of the degree of intellectual 
development of the idiotic children in question. Some idiots, 
e.g., microcephalics, may incoherently chatter for hours, and 
yet be no wiser than those who never utter a single word. 

With few exceptions, idiots are unable to acquire, retain, 
associate or evolve ideas ; reason, judge, or appreciate their ^^^^ 9^ 

• ° ^-^ reasoning 

personality, their actions or their surroundings. Instinctively power, 
they may cling to those who feed and take care of them, like 



574 MENTAL DISEASES. 

animals obey their masters, after prolonged training perform 
certain actions, and even manifest a certain degree of reasoning 
power. In the majority of instances, however, their perform- 
ances are mechanical and automatic. They may for hours lie 
or sit in one position and indulge in certain movements, without 
by attitude or expression indicating the desire for a change, 
or even betraying any discomfort previous to or after the acts 
of defecation or urination. 

As compared with the different varieties of idiocy, intelligence 

Amaurotic- is least allotted to the amaurotic idiot. Deprived of sight and 

devoid of hearing since early infancy, limp and lang^uid as a result of the 

reason. . . -^ ^ "^ 

ever mcreasmg atony of its musculature, the helpless creature 
gradually loses all its senses, and, fortunately, also its life. 
Microcephiles are nearly as badly endowed with intelligence as 
the former group, but their stupidity is not progressive in char- 
acter. As they grow older they are able to feed themselves, 

and with hearing intact they may learn to talk — talk without 
Micro- ^ ,-. . ^ . ,,..,. 

cephalic— sequcucc or measure. Genume microcephalic idiots are ob- 

vulgar 

brutal! stinate, vulgar, and brutal. Almost the exact opposite charac- 
teristics are observed in hydrocephalic idiots. They are or- 
cephaiic— dinarily soft, gentle, timid, sorrowful, but little impressionable 
timid! or curious. As very marked cases of hydrocephalus usually 
succumb at birth or soon after, those surviving usually possess 
a greater degree of intelligence than microcephiles, nay, at times 
they may grow up to be perfectly normal. The mental impair- 
fairiy ment followino[ meningitis, or encephalitis, varies with the extent 

intelligent. . ^ fe ' F ^ 

of the brain lesion produced by the inflammatory process. Deaf- 
mutism, aphasias and amaurosis being common sequelae, little 
intellectual capacity can be expected. In the absence of these 
defects, the little patients may gradually acquire a fair measure 
of intelligence. The same observations practically hold good 
Mongolian— {q^ svphilitic idiocv. Tics and convulsions are not rare in both 

improves ■' ^ ■' 

with age. Qf thesc typcs of idiocy. The Mongolian idiot is a restless 
creature. Totally idiotic in early infancy, he gradually shows 
signs of improving mentality. He learns to appreciate his sur- 
roundings, and to make himself understood by a language of his 
own. He learns to run about at an earlier age than most other 

Cretin- idiots, and not rarely shows destructive tendencies. Under suit- 
improves •' ... . . ,, , 
"Oder able treatment cretins often attain a fair measure of intellectual 

thyroid • • i 

treatment; development. Like hydrocephiles they are timid, gentle, and 
childish, unassuming. They retain their childish tastes for a long time, 



IDIOCY. .■')7.-) 

and sometimes for life, if left untreated. In the latter respects infautiiism 
infantilism differs little from cretinism. In infantilism, however, to^?d'u,5a^-^ 
there is much greater control of the muscular system, and quicker 
response to medication and training. 

Significant as the aforementioned mental stigmata of degen- 
eration are to disclose the existence of idiocy as a whole, they can 



tion. 




Fig. 185. — Hydrocephalic Idiot. (Sheffield.) 

rarely be relied upon in the determination of the exact form of 
the aft'ection. For this purpose the physical peculiarities of idiots 
presently to be related are almost invariably decisive. 



B. Physical Stigmata of Degeneration. 

The cranium of a hvdroceplialic^ (see Fio-. 185 ) is laro-e, ball- Hydro- 

'- ^ ^ * cephalic — 

shaped, and its circumference widest at the temples. It contrasts {^^sf- soft 
strongly with the small, delicate face. The fontanelles are 
separated, the eyebrows are scarcely indicated,, and the mouth 
and nose are small. In microcephalus- (see Fig. 186) the head 
1 See page 124. - See page 123. 



576 



MENTAL DISEASES. 



Micro- 
cephalic— 
small head, 
prematurely 
ossified. 



Syphilitic — 
head irreg- 
ularly 
bossed; 
Hutchinson 
teeth. 



is small, narrow anteriorly and devoid of posterior projection. It 
greatly resembles that of an animal. The fontanelles are pre- 
maturely ossified. The eyes are small, the ears project, and the 
nose and the lower jaw are large. In syphilitic idiots the 
head is unevenly enlarged. The skull is irregularly bossed and 
traversed by prominent blue veins. The nose is often saddle- 
shaped. The upper central incisors are notched. The lips 
are usually thick and the angles of the mouth not rarely marked 




Fig. 186. — Microcephalic Idiot. Fig. 187. — Amaurotic Idiot. 

Status Idioticus 
(peculiar attitude assumed by idiots in sitting posture) . (Sheffield.) 



Mongolian — 
short, pug- 
nose; 
prominent 
cheek 
bones. 



Amaurotic— 

head 

thrown 

forward or 

backward. 



by rhagades. The cranium of the Mongolian (Figs. 188, 189) idiot 
is somewhat smaller than normal, rounded, with the occiput 
running quite parallel with the plane of the face. The face is 
sunken, the nose short and broad and bound laterally toward 
the eyes by distinct vertical folds. The cheek bones are prom- 
inent, and the tongue protrudes. No characteristic physical 
signs of degeneration are apparent on the cranium of the amau- 
rotic idioti (see Fig. 187), except that, owing to the general atony 
of the musculature, the patient is unable to hold up his head. 

1 See page 583. 



IDIOCY. 



Oi t 



The face is delicate. The skull of the cretin^ (see Fig. 190) is 
rather larger than normal, sparsely covered by thin, lusterless 
hair, and set upon a thick, short neck. The face is weak and 
senile, the eyelids and lips are thick, the tongue is heavy and 
often protrudes from the half closed mouth. Meningitic, en- 
cephalitic, or paralytic idiocy (see Fig. 191) usually presents no 
characteristic cranial physical signs, except when due to severe 
traumatism at birth or after. In some congenital cases there 
is marked flattening of the temporal bone of one side corre- 
sponding with the lesion in the brain (porencephalia, etc.). In 



Cretinic — 
puffy face; 
protruding 
tongue. 



Paralytic — 
involvement 
of cranial 
nerves ; 
poren- 
cephalia. 




Fig. 188. — Mongolian Idiocy. (Cahnuck U'pe.) (Sheffield.) 



infantilism (Figs. 192, 193) the skull is smaller than normal, and 
the face is either plump and senile (typus Brissaud), or thin, 
delicate and infantile (typus Lorain). 

The teeth of the great majority of idiotic children are irregu- 
larly implanted, faulty in form, and excessive or deficient in 
number. Owing to irregularity of the dental arches and size 
of the teeth, the patient is frequently unable to close his mouth 
— which should not be mistaken for the open mouth associated 
with nasal obstruction — and the constantly dribbling saliva 
not rarely leads to painful excoriation of the chin. The lips 
are often congenitally malformed. The palate is high and narrow 
and quite frequently clefted. Internal inspection of the nose 
usually reveals numerous deviations from the normal con- 
struction. The ears often project or are asymmetrical. Idiots 

1 See page 488. '^' 



Infanti 

small 

head; 

senile 

face. 



Teeth 

irregularly 

implanted. 



Palate high 
and narrow. 



Bars asym- 
metrical. 



578 MENTAL DISEASES. 

defecUve^ often present divers anomalies of the eyes varying from simple 
errors of refraction to total absence of the eyes. 

Except the presence of pseudolipomatous masses in the 
myxedematous, there are no pathognomonic physical peculiar- 
ities of the trunk which may be helpful in the differential diag- 
nosis between the numerous forms of mental backwardness. 




Fig. 189.— Mongolian Idiocy. (Malay type.) (Sheffield.) 

Thorax ^o^^ idiots are undersized, present more or less marked deformi- 
deformed. |.jgg ^f ^^^ thorax and spine, large abdomen, hernias and narrow 
Hernia P^lves. The genitalia are often undeveloped and malformed. 

The condition of the extremities varies in the different types 

cephafic- ^^ idiocy. The hydrocephile often suffers from paraplegia with 

paraplegia, gpastic rigidity of the muscles, and is thus unable either to 

walk or stand. The upper extremities are usually normal, and 

only occasionally aifected by contractures and athetotic move- 



IDIOCY. 



579 



ments. The microcephalic idiot is an extremely restless creature J^p^°iic_ 
and rarely sits or stands still even if supported. Some few of Rigidity- 
them are completely rigid, and others, when they grow older, 
manage to walk about. The syphilitic, as a rule, are helpless, syphiiitic- 
principally as a result of deformities of the extremities and plrafysis. 
rarefying and softening inflammatory processes at the articula- 
tions. The child walks as if paralyzed, if it can walk at all. The 




190. — Cretinic Idiot (8 years oldj . Note infantile 
appearance and tastes. (Sheffield.) 



Mongolian idiot begins to walk at a much later age than the 
normal baby. His joints are weak, and his hands and feet plump. 
Amaurotic idiocy is characterized by muscular atony which 
gradually terminates in general paralysis. The cretin has a 
peculiar dragging and awkward gait, and often presents deformi- 
ties of the extremities and thickening of the joints. Unilateral or 
bilateral hemiplegia with contracture and athetosis is patho- 
gnomonic of the paralytic idiot. A\'here one hemisphere is 
involved he has a tottering- gait. In infantilism the extremities 



Mongolian- 
plump 
extremities; 
awkward 
gait. 

Cretinic — 

dragging 

gait. 



Paralytic- 
Hemi- or 
di-plegia. 



580 MEiN-TAL DISEASES. 

are apparently normal in shape, but their musculature is weak 
Backward and flabby. A radiogram (see Figs. 194, 195) of the hand 
^^^f^cSpai usually reveals backward development of the centers of ossifica- 
tion of the carpal bones and of the epiphyses of the metacarpals 
and phalanges. 




Fig. 191. — Paralytic Idiot (following obstetric cerebral paralysis). 
(Sheffield.) 

In addition to the aforementioned stigmata of degeneration 
idiots often present asymmetry, malformation, superabundance or 
^of'^fiSerf deficiency of fingers and toes (see Fig. 193), club-foot, anky- 
loses, dislocation of the extremities, diastases (see diastasis 
recti abdominis, Fig. 37), and, as a result of lesions in the 
brain and spinal cord, divers forms of paralyses and contract- 
ures, and local and general atrophies, etc. 

With due appreciation of the mental and physical pecuHarities 
of the various forms of idiocy, there is rarely any difficulty in 



IDIOCY, 



581 



arriving- at a correct diagnosis 



The importance of early individ- 
ualization cannot be too strongly emphasized, for, with a full 
knowledge of the type of idiocy a great deal can often be accom- 
plished in the way of treatment. I am referring especially to 
the phenomenal success obtained from the administration of 



Importance 
of early 
diagnosis. 





Fig. 192. — Infantilism. (Typus 
Brissaud.) Child six years old, 32 
inches in height. (Sheffield.) 



Fig. 193. — Infantilism. (Typus 
Lorain.) Five years old, 31 inches 
in height. Acts like two-year-old 
baby. Note absence of left thumb 
and rudimentary development of 
right thumb. (Sheffield.) 



thyroid gland in cretinism (q.v.), and the great improvement in Thyroid 
milder forms of idiocy (irnbecility) that results from systematic treatment, 
methods of training and education. It is greatly to be regretted 
that the laity and the physician alike are so little interested in the 
humanitarian problem of providing suitable training schools for 
the amelioration of the unfortunate condition of the idiot and 
mentallv defected. 



Trainini 



Education. 



582 



MENTAL DISEASES. 




Yig, 194._Skiag-ram of Wrist of Normal Child Six Years 
Old. Note greater number of carpi than in idiotic wrist. 
(Sheffield.) 




Fig. 195.- 



-Skiagram of Wrist of Idiot Ten Years Old. 
absence of several carpi. (Sheffield.) 



Note 



AMAUROTIC FAMILY IDIOCY. 583 

For details of treatment of hydrocephalus, microcephalus, 
cretinism, etc., the reader is referred to the respective chapters on 
the subjects in question. 




Fig. 196. — .-\maurotic Family Idiocy (14 months old). Note 
inability to hold up head. (Sheffield.) 

AMAUROTIC FAMILY IDIOCY.i 

This type of idiocy occurs in several members of the same 
family and shows a predilection for those of the Hebrew race. 
Its etioloery is still obscure. While all observers agree that . 

^■^ ° . Arrested 

it is due to arrested development and sequential degeneration development. 




Fig. 197.— The Normal Fundus of the Right Eye. (Henle.) 

first of the gray matter and later of the white fibers of the brain 
and cord, it is still undecided whether the degeneration is 
of antenatal or postnatal (toxemia) origin. The very recent 



Toxemia. 



1 To B. Sachs, of New York, we are indebted for the name and most 
of the knowledge of the disease in question. 



584 MENTAL DISEASES. 

observation that there is also a ''late" form of this disease seems 
to point in favor of its being acquired. 

However this may be, the symptom-complex is very charac- 
"^^trth. teristic. The normally born infant which seems to thrive fairly 
well up to about 4 or 8 months begins to show symptoms of 
debility and atony of the entire musculature. As it grows older, 
the mental development, instead of progressing normally, fails 
to come up to the normal standard, so that it soon becomes 
evident that the infant is absolutely idiotic. Further examination 




Fig. 198. — Macular Change [cherry-red color] in Amaurotic 
Family Idiocy. {Tay.) 

Blindness, rcvcals that the child sees very little or not at all (due to degen- 
eration of the papilla and optic neuritis; there is a grayish-white 

Defective cloudiucss around the cherry-red macula), and that its hearing, 

hearing, while at first hyperacute, gradually becomes obtuse. The optic 

atrophy and general paresis are usually complete when the child 

is 1 year old. At a later stage of the affection there are also 

nystagmus, strabismus and ''explosive laughter." 

With careful attention — fresh air; good food; care of the 
skin ; frequent change of position to prevent hypostatic pneumonia 
—the patients may continue to exist up to about 2 years old; 
without suitable care, however, they usually succumb at an 
earlier period from marasmus and exhaustion, the latter often as 
a result of inanition subsequent to difficult deglutition. 



Fatal. 



KATATONIA. .IS.") 

For the differential diagnosis between amaurotic and other 
forms of idiocy, see page 570. 

IMBECILITY 

(Feeble-mindedness) . 

Imbecihty is closely related to idiocy, and is based upon some inherent 
inherent mental priA'ation which no amount of education can privation. 
entirely overcome. The condition is usually not detected until 
the child goes to school, when it is found that as compared with 
the normal pupil he is backAvard in understanding and reasoning, 
though he may be singularly dcAxloped in special directions, e.g., 
memory, mechanical aptitude. Further obserA^ation rcA^eals also 
that the imbecile is exceedingly emotional, easily irritated and 
appeased AA'ith difficulty, shoAA'S an irresistible passion to lie, steal 
and play truant, and that long before maturity his sexual inclina- 
tions are in the hig^hest state of depraA'itA'. His moral decrepitude 
mcreases from year to year, and may range trom theft, arson and decrepitude. 
rape to homicide and suicide. 

Imbeciles should be placed under the control of experienced 
pedagogues, preferably in some lonely country place. 



KATATONIA 

(Hebephrenia), 

This mental affection is usually encountered in children OAxr 
ten years of age. and especially in girls at the period of puberty. 
It usually begins Avith a prodromic stage of depression and apathy Depression. 
during Avhich the child loses interest in her school AA'ork, and 
complains of dn^ers imaginarA' ailments. This stage is soon fol- 

. , . . . '.,,... . . . Halluclna- 

lowed by one ot anxiety and hallucmations or outbreaks ot tions. 
emotional excitement, silly and hilarious in nature. As the dis- 
ease advances, the condition is often complicated by manifesta- 
tions of mania with a marked tendency to destructiA^eness and Mania. 
Adolence, occasionally also by attacks of stupor, catalepsy, affec- 
tions of speech, refusal of food, conA'ulsiA'e moA'ements, etc. 

In faA^orable cases the mental disturbance gradually subsides 
Avithin a few Aveeks or months, often leaving behind symptoms of 
imbecility. In unfavorable cases the disease passes into a state 
of total idiocy. Little, if anything, can be done to influence the 
course of the aft'ection. 



586 MENTAL DISEASES. 

MELANCHOLIA. 

Depression. Depression of spirits is not rarely observed in children from 
ten to fifteen years of age and sometimes even in younger ones. 
The child refuses to play, laments and cries, broods over imagi- 
nary wrong acts, and occasionally falls into paroxysms of rage, 
to self- Melancholia not rarely leads to attempts of self-destruction. 

The prognosis of this affection is fairly favorable (after 
weeks or months) ; some cases, however, may proceed to mania 
or even dementia. Rest and good food are essential in the treat- 
ment. 

MANIA. 

Physical ^^ Contrast to melancholia mania is characterized by accelera- 

^"•^ hype?- ^^^^^ ^^ every physical and mental activity. Thoughts and 

activity, impulses follow One another with unusual rapidity. The patient 

talks, rages, screams and tries to destroy everything in sight. He 

also suffers from hallucinations and delusions of greatness. 

While mania often ends in recovery after from six to twelve 

months, it also shows a great tendency to recurrence or to alter- 

Recurrences. ^^^^ ^'^^-^ attacks of melancholia — circular insanity — in which 

event the prognosis is very bad. 

The treatment, in addition to rest and proper nourishment, is 
symptomatic — calming of the excitement by means of hyoscine 
hydrobromate. 

DEMENTIA. 

Acute dementia is rare in children under twelve years of age. 
It is apt to follow severe infectious diseases, such as typhoid fever 
or scarlatina, or sudden shock and mental and physical over- 
exertion. It is manifested by gradual weakening of the mind, 
Loss of characterized by loss of memory, lack of power of attention, 

memory; . -^ , . -^ '■ 

stupor, interest, and curiosity and tendency to stupor. After weeks or 
months of rest, ample nutrition and tonic treatment there is 
usually a progressive return of intellect and gradual recovery. 
More rarely it terminates in permanent weak-mindedness. 

Dementia paralytica, which is very uncommon in children and 
Paralysis; usually bascd upou hereditary syphilis, presents identical symp- 
sMrringf toms as in adults. Thus, tremor, slurring speech, pupillary 
inequahty, ataxia, trophic changes, and paresis; gradual loss of 
intellect with development of unsystematized ideas of self-impor- 
tance. The course of this form of dementia is chronic (several 



HYSTERIA. 587 

years) and invariably ends fatally. Slight improvement may 
occasionally be obtained from cautious use of mercury and the 
iodids. 

HYSTERIA. 

Hysteria is a neuropsychosis, a product of faulty environment 
and education.! It is rare in children under eight years of age, 
but quite common' in older ones, and especially in girls. 

The onset of hysteria can frequently be traced to some sudden 
violent emotion (shock) with, or, more rarely, without bodily shock; 
injury. The attendant circumstances at the time of the psychic 
disturbance often serves to determine the seat of the hysterical 
lesion, e.g., hysterical deafness after explosion, paralysis or con- 
tracture of an extremity, after a trivial injury. 

The symptomatology of hysteria is characteristic for its mul- 
tiplicity and mutability. It may closely simulate that of any 
organic disease, but its spuriousness can usually be detected after 
careful scrutiny. The diagnostic perplexities augment, however, 
with accidental concurrence of some acute affection or pre- 
existence of a chronic organic disease. 

Paralysis of the extremities with or without contracture forms Paralysis of 

. . . .. . extremities. 

a frequent hysterical manifestation. It may appear in the form 
of paraplegia, monoplegia or hemiplegia, and thus resemble 
myelitis, poliomyelitis or cerebral paralysis. , In hysterical Differentia- 
"spinal" paralysis, however, there is rarely absolute loss of mus- spinal and 

^ ^ •> ^ _ -' _ _ cerebral 

cular power. Muscular atrophy is absent or slight, and electric paralysis. 
irritability remains normal. In hysterical "cerebral" paralysis 
also the loss of power is rarely complete and the leg is often more 
affected than the arm. The face usually remains uninvolved. A 
peculiar form of either continuous or intermittent pseudoparal- 
ysis is occasionally met in children, which has been described by 
Blocq as astasia-abasia. In this condition the muscles of the Astasia- 

^ _ _ abasia. 

lower extremities can be freely used except in standing or walk- 
ing. If the latter is attempted, the patient immediately falls to 
the ground or begins to tremble and topples over, or manifests 
ataxic symptoms {cerebellar type). The difficulty in walking is 
sometimes overcome after a few steps are taken. 

The hysterical contractures may involve the articulations, 
groups of muscles or a part of a muscle. As a rule, the joints of contractures. 



1 ''A Contribution to the Study of Hysteria in Children," by Dr. H. B. 
Sheffield, New York Medical Journal, September 17 and 24, 1898. 



588 MENTAL DISEASES. 

the tapering extremities are most frequently affected. All sorts 
Differentia- of deformities may arise which may greatly resemble genuine joint 
^"Sifla^ and bone disease (e.g., hip-joint disease, spondylitis, tahpes, etc.), 
deformttieZ and lead to errors in the diagnosis. The more sudden onset, the 
irregularity of its course, the tendency to change its situation, and 
the concomitance of other evidences of hysteria, all help the 
exclusion of organic disease. At a later stage the diagnosis of 
hysterical contracture can frequently be made by the absence of 
local thickening, or active inflammation of the bone or muscle and 
its disappearance under anesthesia. Where a part of a muscle is 
affected the contracture may give rise to circumscribed swellings, 
tumor. Allied in nature are also the so-called "phantom tumors" occa- 
sionally observed on the lower portion of the abdomen, and the 
Ballooning. pecuHar "ballooning" of the hypogastrium manifested Avith each 
expiration. Occasionally the abdominal enlargement is general 
and not rarely accompanied by local tenderness. Furthermore, 
the hysterical tympanites may be associated with vomiting, ano- 
rexia, singultus, disturbed respiration, retention of the urine, etc., 

Differentia- . , . . , ,. . , . . , . . i • i 

tion from and thus givc risc to the clmical picture of peritonitis which may 
test the skill of even the best diagnostician. As a rule, obstipation 
and fever are absent in these cases and the vomitus is not so per- 
sistent as in true peritonitis. Of course, vomiting, anorexia, 
tachypnea, etc., may exist independently of the hysteria and 
greatly obscure the diagnosis. 

The symptoms thus far enumerated represent principally the 
neurotic element of hysteria. To those may be added the occa- 
cataiepsy. sionally occurring cataleptic states, spasm of the laryngeal mus- 
cles (croup), dysphagia, aphonia, aphasia with spells of coughing, 
Amaurosis, singing or stuttering, asthma, amblyopia, hemianopsia, contraction 
of the visual field, amaurosis and blepharospasm. 

In another s^roup of cases the psychic element predominates. 

Psychic . . 

listurbances. Here too, howcver, there is generally a great display of spasmodic 
and convulsive movements ranging between simple or choreic 
tremor to marked epileptiform convulsions (hysteroepilepsy). 
The movements may assume the form of athletic exercises, such 

Chorea , . •' 

rhythmica. as rowing. Swimming, punching, etc. — chorea rhytlunica ; or the 
magna, patient may act as though possessed, climb walls, turn somer- 
saults, and perform all sorts of stunts — chorea magna. Still 
more advanced cases of hysteria may be manifested by attacks 
of sopor, night terrors, somnambulism, hallucinations, delirium 
and mania. 



HYSTERIA. 589 

Hysteroepilepsy is comparatively rare in children. An attack Sjfepgy" 
is usually preceded by emotional excitement, globus hystericus, 
etc., and may be induced by pressure upon sensitive areas — 
hysterogenic zones — of the body, such as the hypochondriac or 
spinal regions. Hysteroepilepsy differs from genuine epilepsy J^on^from^' 
in the following respects: — fpfiepsy. 

Epilepsy. Hysteroepilepsy. 

Onset sudden. Preceded by emotional excitement. 

Consciousness entirely lost. Partially preserved. 

Convulsions pre-eminently clonic. Tumultuous, accompanied by moan- 

ing, screaming, crying, etc. 
Duration short, followed by stupor. Longer; followed by restlessness. 

Hysteria generally proceeds a very chronic course, with tem- 
porary improvement and relapses. Of course, it very much 
depends upon the etiologic factors, the time when treatment is 
begun and the energy with which it is carried out. 

Without denying the transmissibilitv from parent to oft'spring 

, - . ,.,.",., ,. Usually 

o± a certain degree of nerve instability which may predispose to acquired 

, . . , . . . . , . ,. .by imitation. 

hysteria, m the great majority of instances this disease is 
acquired as a result of harmful influence of faulty environment 
and education. A child repeatedly seeing its mother, for example, 
in a state of emotional excitement or frenzy, sooner or later, con- 
sciously and deliberately, or otherwise, learns to imitate its 
mother's hysterical performances, the habit of imitation gradually 
leading to aberration of the normal cerebral functions. Unable 
as the mother is to control her own abnormal actions and feel- 
ings, she can hardly be equal to the occasion to guide her children 
in the right direction. On the contrary, the child is allowed to 
have its own way, is made the central figure of the household, and 
spoiled by overtenderness. If in addition such methods of educa- 
tion are adopted as will overtax the child's mental capacity (e.g., 
the study of music, painting, emotional recitations, etc., in addi- 
tion to arduous school work), a deranged state of mind sooner 
or later supervenes which is most susceptible to the aforemen- ^^^^^ 
tioned pernicious influences. Less potent factors in the predis- ^auses^°^^°^ 
position to hysteria are : The use of alcoholic beverages, acute 
infectious diseases, prolonged disturbance of the sexual (mastur- 
bation!), digestive and circulatory (anemia) systems, in fact, 
anything that will undermine the physical or mental condition of 
the child. 

With these principal etiologic factors in view the indications 
for the treatment of hysteria in children are self evident. The 



590 



MENTAL DISEASES. 



Outdoor 
life. 



Suitable 
nutrition. 



patient should be removed from the hysterical environment, and 
Discipline, placed Under the care of one who with kindness but firmness can 
control its destiny. Change of residence from the noisy city to 
the restful country often works wonders. The child should lead 
an outdoor life, and every effort should be made to raise its gen- 
eral bodily development. The food should be ample and nutri- 
tious, free from alcoholic beverages. Milk foods should be given 
preference to meats. The education should be restricted to the 
simplest school work, or, for a time at least, entirely suspended. 
The active treatment of hysteria is essentially symptomatic, 
therapy. Warm baths and cold showers and general massage are useful in 
all cases. Paralyses and contractures frequently yield to elec- 
suggestion. tricity, its action being probably suggestive in nature. Suggestion 
by electricity or other spectacular procedures is also effective in 
relieving local conditions, such as aphonia, stuttering, blindness, 
and the like. Hysteroepilepsy and maniacal outbreaks call for 
Isolation, isolation, rest in bed and the administration of small doses of 
the bromids and valaria. Disregard of the patient's complaints 
and severity will often cure all sorts of hysterical phenomena 
where kinder therapeutic measures ordinarily fail. 

IJ Ext. humuli fl 3iij I 12 

Infusi Valerianae, | 

Aq. aurantii flor aa §j | 30 

M. Sig. : 3j every four hours for a child 10 years old. 



CHAPTER XVI. 
Diseases of the Skin. 



Skin affections of children like those of adults may be classi- 
fied into systemic and local. To the former class belong chiefly systemic. 
the large group of exanthemata ; the rashes arising as a result 
of faulty metabolism and autointoxication, including the dift'erent 
forms of purpura, erythema and drug eruptions; the syphilides 
and tuberculous lesions and the obscure dermatoneuroses. The 
local skin diseases embrace the local parasitic affections, the Local, 
lesions following mechanic, traumatic, thermic and chemic irri- 
tations. 

As the greater number of morbid skin manifestations have 
received due consideration in connection with the underhung dis- 
eases, we shall here limit our discussion to the skin eruptions 
which yield principally to local treatment. 



ECZEMA. 

Eczema in children is usually observed in subacute or chronic 
form. It ordinarily begins with localized, more rarely dift"use, 
redness of the skin, slight edema, burning and itching. The con- ^^^e^^af ' 
dition is soon aggravated by the appearance of papules, vesicles aSd°^°^ 
and pustules, and, if not promptly responding to treatment, by ^^^^^^s- 
scabs, scales and fissures. 

Eczema may remain localized, especially on the face and head, 
or become generalized. Eczema of the face and head is usually 
seen in young infants, and is very refractory to treatment. In 
its typical form, the eruption of eczema faciei is generally spoken 
of as "crusta lactea," and consists of more or less coherent scabs 
of greenish or blackish-brown color, here and there interrupted 
by areas of red, moist ("weeping surface''), and excoriated skin. 
From the face the eruption usually extends to the forehead, ears 
and head (eczema or seborrhea capitis). After prolonged dura- 
tion the hair loses its luster, becomes thin and short and the 
adjacent glands are painful and swollen, and often the seat 

(591) 



Crusta 
lactea. 



Adenitis. 



592 



DISEASES OE THE SKIX 



of a pustular eruption as a result of scratching and secondary 
infection. 

The course of eczema is very tedious. It may last weeks, 
Chronic mouths, or years. Improvement often alternates with aggrava- 
tion of the condition. This is true especially of eczema accom- 
panying constitutional derangement, e.g., gastrointestinal intoxica- 




Fig. 199. — Seborrheic Eczema of Head and Face, {^.shcjjicki.) 



tion. The duration of the disease is often greatly prolonged by 

Secondary * • i i- 

infection, infection of the diseased as well as healthy areas with divers para- 
sites during the act of scratching. 

The success in the management of eczema depends greatly 
upon the ease with which the underlying causes can be prevented 
or removed. The infantile skin being very delicate and vul- 
nerable, it is essential to avoid its undue exposure to mechanical 
(scratching; woolen, rough underwear, etc.), thermal (excessive 
, .^ heat or cold, also direct action of the sun, etc.) and chemical 

Avoid ' 

irritation, (rubefacients, irritating soaps, urine, acrid discharges, etc.) 



ECZEMA. 



593 



irritation. The diet should be bland (not too rich in fat), and 
regulated as to the time of feeding and its quantity. Constipa- 
tion should be promptly remedied. CleanHness of the skin and 
everything coming in contact with it should be insured. 

The active treatment of eczema should be regulated in accord 
with the stage of the disease. While the skin is highly inflamed, 
all sorts of irritation should be interdicted. Tub-bathing of the 
entire body should be discontinued for a time, firstly, because of 
the tendency of water to irritate the denuded skin, and, secondly, 
in view of the possibility — particularly in eczema due to 
external parasitic infection — of conveying the disease from one 
portion of the skin to the other. The healthy parts of the body, 
however, should be kept scrupulously clean by frequent sponging, 
followed by careful drying. 

The following soothing and protective ointment, employed 
with great success at the New York Post-graduate Hospital, will 
be found invaluable in the great majority of acute or subacute 
cases : — 



Correct 

faulty 

diet. 



Avoid 

excessive 

moisture. 



Protective 
ointments. 



I^ Zinci oxidi, 

Pulveris cretse aa 3iv | 16 

Mix, and add with constant stirring : 
Olei lini (hot), 
Liq. phmibi subacet. dil aa 3ij | 8 



The ointment is applied once or twice a day thickly over the 
affected areas and covered by sterile gauze held in place by means 
of a bandage. Scratching of the skin should be prevented by 
mechanical means, such as celluloid armlets, and the like. Ex- 
coriated surfaces often heal promptly after painting with a 2 per 
cent, solution of nitrate of silver. 

After the inflammation subsides and scales and crusts firmly 
adhere to the skin, the soothing ointments are gradually replaced 
by those of a stimulating nature. The crusts are softened with 
carbolized oil (1 to 100), and gently removed. The hairy por- 
tions of the body are carefully shaved and cleansed with car- 
bolized oil. After giving the affected skin a few hours' rest we 
apply one of the following preparations : — 

I^ Acidi saHcyHci, 

Bismuthi subgal aa gr. xx | 1.3 

ThymoHs gr. v | 0.3 

Pulveris amyli 3iij | 12 

Ung. hydrargyri ararnoniati 3ij I 8 

Ung. zinci oxidi q. s. ad Sij | 60 

38 



Prevent 
scratching. 



Stimulating 
ointments. 



594 



DISEASES OF THE SKIN. 



Intestinal 
irrigation. 



I^ Resorcini gr, xx 

Acidi carbolici gr. x 

Olei cadini 7» xx 

Sulphuris precipitatis 3ij 

Ung. petrolati q. s. ad Sij 



1.3 
0.65 
1.3 
8 
60 



High intestinal irrigation once a day with a quart or two of 
plain water or with the addition of 2 per cent, of bicarbonate of 
soda is useful in all cases. In gastric hyperacidity carbonate of 
magnesium (gr. xxx, once a day) acts well. Obese children 
suffering from obstinate eczema with dryness of the skin often 
do well on minute doses of thyroid extract. Finally, it is worth 
remembering that protracted eczema is occasionally a manifesta- 
tion of hereditary syphilis, and responds promptly to the exhibi- 
tion of mercury and the iodids. 



Transient 

multiform 

eruption. 



'Wheals.' 



Tendency to 
prurigo. 



URTICARIA 

(Hives, Nettle Rash). 

Urticaria is characterized by a multiform eruption of whitish, 
pinkish or reddish color upon different portions of the body, 
which is sudden in appearance and disappearance, and shows a 
tendency to repeated recurrences. The eruption may consist of 
circular or spiral elevations (''wheals"), papules, vesicles, or 
hemorrhagic spots, and is generally associated with intense itch- 
ing and stinging. It is frequently preceded and accompanied by 
gastric and nervous disturbances and rise of temperature. 

Recurrent urticaria is prone to leave behind marked pigmenta- 
tion of the skin or to terminate into prurigo, a very chronic skin 
affection manifested by dryness, hypertrophy and pigmentation of 
the skin and inflammation of the neighboring glands. 

As in the majority of instances, urticaria in children is the 
fSd^ng^ result of faulty feeding, especially of eating candies and cakes of 
poor quality, fish, fresh berries and the like, it is essential 
promptly to regulate the diet, and to clear the gastrointestinal 
tract of the obnoxious material. The latter is best accomplished 
by small doses of calomel, magnesium carbonate and sodium 
bicarbonate and a high enema. To relieve itching we may resort 
to warm baths with bicarbonate of soda (^ to 1 pound) ; sponging 
of the body with vinegar followed by glycerin, or to the following 
preparations : — 

U Thymolis gr. v to x | 0.3 to 0.65 

Ung. aquae rosse t] | 30 

Sig. : P. r. n. 



PSORIASIS. r)!).") 

R. Aquje ammonije 3ss | 2 

Aquse hamamelidis 5iij I 90 

Sig. : P. r. n. Not to be used over al)raded portions of the skin. 

INTERTRIGO 

(Chafing). 

This affection occurs with predilection in localities where 
opposed body surfaces rub against each other, and in the "napkin 
region." It is the result of irritation of the skin by acrid secre- 
tions or excretions (sweat, diarrheal stools, acid in-ine, purulent 
discharges, etc.), excessive heat or moisture. Intertrigo usually 
begins with simple erythema. At this stage it readily yields, in 
addition to removal of the etiologic factors, to the application of 
a dusting powder of : — 

IJ Zinci stearatis 3iv | 15 

Bismiithi snbnitratis gr. xv | 1 

Amyli 5j j 30 

and the separation of the apposed surfaces by thin layers of 
absorbent cotton. As the disease advances, the skin becomes ^, 

Glossy, 

glossy, moist, sticky, and denuded of epidermis, and the seat of °ioist 

^-^ •' , .... . redness. 

papules, abscesses and ulcerations. In this condition intertrigo 
is very refractory to treatment, often demanding a complete 
change in the regime of the baby — beginning with its diet and 9j^J^^® °^ 
ending up with its nurse. The customary daily tub-bath should nurse. 
be replaced by a sponge bath, taking special care to keep the 
affected parts of the skin perfectly dry. The denuded skin should 
once daily be painted with a 1 or 2 per cent, solution of nitrate ^ivel-*^ °^ 
of silver, and the entire diseased surface covered with the fol- 
lowing ointment : — 

I^ Acidi carbolici. 

Balsami Peruviani aa m v ! 0.3 

Olei Hni, | 

Adipis lanse, j 

Ung. zinci oxidi aa 3iv j 15 

Sig. : To be applied several times a day after carefully cleansing (with 
oil) and drying the affected parts. 

PSORIASIS. 

The disease is very exceptionally met in children under five 
years of age, but is not uncommon in older ones. It begins with 
minute white spots usually upon the extensor surfaces of the ^.^L^J^" 
elbows and knees and upon the scalp, and gradually assumes the l^^^^\ 
shape of disks with tawny-red base and silvery-white scales, not ^^^e. 



596 



DISEASES OF THE SKIN. 



rarely giving the skin the appearance of having been splashed 
Probably with mortar. The cause of psoriasis being obscure (apparently 
parasi ic. ^£ parasitic origin, though it seem to run in famiHes), the treat- 




Fig, 200. — Psoriasis in a Girl Seven Years Old. (Sheffield.) 

ment is necessarily symptomatic, and very unsatisfactory as to 
ultimate cure. Internally we may try small doses of arsenic, to 
Arsenic. ^^ Continued for several months, or thyroid extract. Externally 
we resort to alkaline baths, and, after removal of the scales, to 
an ointment composed of chrysarobin or salicylic acid and 
ichthyol. 

R. Acidi salicylici, 
Resorcini, 

Ichthyoli aa 3ss I 2 

Ung. sulphuris 8ij j 60 

Sig. : To be applied twice a day. 

I^ Chrysarobini, 

Ichthyoli aa 3j |. 4 

Ung. petrolati §ij I 60 

Sig. : To be applied once or twice a day. 



HERPES ZOSTER. 



597 




Fig. .:l!Jl. — Psoriasis of the Legs. {Sliocinaker.) 



HERPES ZOSTER 

(Shingles). 

Contrary to what is observed jn adults, herpes zoster in 
children is rarely accompanied by severe neuralgic pain. The 
eruption usually appears suddenly in the form of groups of 
vesicles alons^ the tracts of either the intercostal or pudendal vesicles 

^ ... along 

nerves, or the brachial plexus. The vesicles remain either 
isolated or coalesce and form large patches covered by yellowish- 
brown crusts. Different patches often exhibit different stages of 
development or decline. As a rule, the eruption is unilateral. 

The course of the disease is usually completed within two 
weeks, except in cases leading to deep ulceration and sloughing ^0°^^^^°^ 
(herpes gangrenosus), a veiy rare condition, usually the result of 
secondary infection. The treatment consists of local application 



nerve 
tracts. 



598 DISEASES OF THE SKIN. 

of a dusting powder or ointment composed of stearate of zinc 
with or without 2 per cent, of bismuth subnitrate or subgallate. 
Occasionally the nerve pain calls for some anodyne, e.g., sodium 
Salicylates, salicylate. 




Fig. 202. — Herpes Zoster. (SJieffield.) 

MILIARIA; LICHEN STROPHULUS 
(Prickly Heat). 

This very common affection in infants, especially during first 

dentition, appears suddenly upon the face, trunk and extremities 

"^^^Snot ^it^^^i' ^s discrete papules or vesicles from a pinhead to half a 

infected, pg^ [-^ gj^e, or in groups upon a slightly reddened infiltrated base. 

It is produced by all sorts of external or internal irritations (heat, 

rough flannel underwear, overfeeding, etc.), and readily yields to 



Gangrene. 



IMPETIGO CONTAGIOSA. 599 

attention to these causes, and the administration of mild laxatives. 
The slight itching may be relieved by alkaline or bran baths, and 
sponging of the body with Dobell's solution. 

ECTHYMA 

(Pseudofurunculosis). 

It consists of pea- to bean-sized, flat pustules surrounded by a 
red zone. The lesions are situated chiefly upon the thighs, legs, pustules 

■^ y o ' o ' surrounded 

shoulders and back and are frequently associated with eczema — ^y red 

. . zone. 

probably produced by infection of the eczematous lesions during 
the act of scratching. 

Occasionally the pustules enlarge gradually and burst, leaving 
behind deep ulcers which heal very slowly with scar formation, ulcerations. 
These are prone to occur in ill-fed, scrofulous or otherwise 
seriously diseased children, and may sometimes end fatally as a 
result of gangrene of the skin. 

Simple ecthyma usually responds to hot baths, antiseptic 
ointments, or sponging of the affected parts of the body with the 
following : — 

I^ Etheris, 

Tr. saponis viridis aa 8j | 30 

Large pustules should be treated by incision and antiseptic 
dressings. (See "Scrofulosis/'' page 370.) 



IMPETIGO CONTAGIOSA. 

The favorite seat of impetigo is the face, hands and scalp, but 
the other portions of the body are not exempt from inoculation. 

The eruption begins as small groups of minute vesicopapules 
which soon burst and dry up into yellowish crusts. When a 
crust has lasted for some time its surface becomes slightly lamel- 
lated and its edge detached, the crust then presenting the appear- 
ance as if ''stuck on" to the healthy skin. The surface beneath afpeararSe. 
the crust is raw and suppurating. 

If further autoinoculation of the disease is prevented, impetigo 
usually heals spontaneously in about ten days. Otherwise, by the 
development of new lesions, it may persist for several weeks. 

In view of the highly contagious nature of the disease and its ^^^^^^^°^^- 
tendency to run in epidemic form through schools or asylums, it 
is imperative to isolate all those children who are suffering from 



600 DISEASES OF THE SKIX. 

this disease and to employ active therapeutic measures to eradi- 
cate it. 

This is readily accomplished by means of local antisepsis. 

After softening the crusts with warm carbolized sweet oil (1 per 

cent.), and removing them, and thoroughly washing the diseased 

surface with soft green soap, the spots are touched up with a 

2 to 5 per cent, solution of nitrate of silver, and covered over 

with sterile gauze and adhesive plaster. This treatment is 

repeated for a few days and followed up with a 2 per cent. 

ichthyol in a 10 per cent, sulphur ointment. 

Differentia- Simple impetigo differs from the contagious variety by its 

•°^impie lesions being pustular from the beginning and by showing no 

impe 1^,0. ^gj-^(-|^j-^^^^- rapidly to coalesce in large patches and to spread to 

other portions of the body. There is no history of contagion. 

PEDICULOSIS CAPITIS 
(Head-lice). 

The favorite seat of the head-louse is the occipital portion of 

the scalp. In cases where the hair is thick and the parasites are 

few in number and hence not easily seen, their presence can 

readily be surmised by the existence of ova (nits), which are 

firmly attached to the shafts of the hair. The lesions produced 

^^!^°i^!^ bv pediculi resemble those of eczema of the head — intense itch- 
eczema. ' ^ 

ing, pustules, scabs, matting of the hair, and marked enlargement 
of the glands of the neck. 
Isolation Children affected by pediculosis should be isolated for a few 

days until the disease is cured. The hair should be clipped, the 
scalp thoroughly cleansed with the tincture of green soap, and 
then dressed with a cloth dipped in petroleum or the tincture of 
larkspur (delphinium). A few such dressings usually suffice to 
effect a cure. After removal of the pediculi the scalp should be 
cleared of its remaining eruption by an antiseptic ointment. 

PEDICULOSIS CORPORIS 

(Body-lice). 

Itching. Body-lice are seldom seen in young children. They give rise 

to red dots, itching, and scratch marks. The diagnosis is settled 

by finding the parasite in the clothing or on the body of the child. 

The treatment consists in destroying or baking the infested 

garments, scrubbing the child's body with green soap, and the 



SCABIES. 



GOl 



application of a zinc and sulphur ointment until the eruption has 
entirely disappeared. 

PEDICULOSIS PUBIS 

(Crab-lice). 

This skin affection is of diagnostic interest principally 
because of the power of the crab-louse to infest (in addition to the 
hair of the pubis, abdomen, chest and axilla) also the eyebrows infection of 
and eyelashes, in the latter case giving rise to a clinical picture lyeias^hes^"^ 
resembling blepharitis. 




Fig. 203.— Phthirius Pubis [Crab-louse]. (After Laiidois.) 

The insect succumbs rapidly to the eft'ects of mercury 
ointment. 

IJ Ung. hydrarg. nitratis 3j { 4 

Ung. petrolati 3iij 12 

M. Sig. : Externally once a dav. 



SCABIES 

(The "Itch"). 

The eruption of scabies is localized chiefly in places where 
the skin is thinnest, i.e., the hands, the folds between the fingers, 
the flexor surfaces of the wrists, the anterior fold of the axilla, 
also the back and lower extremities. The characteristic skin 
lesion of scabies is an irregularly shaped, brownish-black ridge 
(cuniculus or furrow), the result of the burrowing process of 
the Acarus or Sarcoptes scabiei. The latter is the cause of 
scabies and can readily be demonstrated microscopically in the 
scrapings of the cuniculus. As the disease advances, it fre- 
quently spreads over the entire body and gives tise to a multi- 
form eruption, consisting of papules, vesicles, pustules and 
heriiorrhagic spots (scratch marks). It is accompanied by violent 
itching, which is worse at night, when the patient is warm in bed. 

As the disease is highly contagious (conveyed through close 



Localized 
chiefly 
where 
skin is 
thinnest. 



Acarus 
scabiei. 



Itching 
worse at 
night. 



602 DISEASES OF THE SKIN. 

bodily contact, clothes, underwear and bedding), it is advisable 
Isolation, to restrict the patient from too closely mingling with other mem- 
bers of the family or outsiders. The patient's clothes, bed-sheets, 
towels, etc., should be boiled, and the other unwashable articles 
o?ciotheJ! thoroughly disinfected. Furthermore, all inmates of the house 
should be examined and, if necessary, treated for scabies, lest the 
disease will recur through renewed infection. 

The treatment of scabies varies with the stage of the disease. 
Green Incipient scabies responds promptly to a few hot baths, thorough 
baths, scrubbing of the affected skin with soft green soap and the 




Fig. 204. — Sarcoptes Scabiei. Female seen from Above and Below. 
(After Gudden.) 



Sulphur, inunction of sulphur ointment with 1 per cent, carbolic acid. The 
management of advanced scabies with the same therapeutic 
measures is not quite as satisfactory. A number of remedies 
(strong ointments of carbolic acid, naphthol, creolin, etc.) have 
been suggested for such cases, but owing to their irritating 
qualities (upon the skin and kidneys) should be used with caution. 
The following combination will probably be found to do well in 
the majority of cases : — 

B Mentholis, 

Pulv. camphorae aa gr. x | 0.65 

Olei cadini, | 

Balsami Pertiviani aa 3j | 4 

Ung. sulphuris q. s. ad 5ij | 60 

M. Sig. : To be applied in the evening after a hot soap bath. 

I^ Acetanilidi 3ss | 2 

Ung. zinci oxidi 5j | 30 

M. Sig. : To relieve irritation. 



TINEA TRICHOPHYTINA CAPITIS. 



603 



TINEA TRICHOPHYTINA CAPITIS 

(Ringworm of the Scalp, Herpes Tonsurans). 

Ringworm of the scalp is due to the trichophyton fungus. It 
is highly contagious and often spreads with great rapidity and 
pertinacity in schools and children's homes where great numbers 
of inmates are crowded in comparatively small rooms. 

The eruption consists of ring-shaped, slightly elevated, scaly, 
reddish, grayish, or greenish-yellow patches. The hair over the 
affected areas becomes brittle and loose and falls out, leaving 
behind bald and shiny spots. 



Highly 
contagious. 



Brittleness 
of hair. 




Fig. 205. — Trichophyton Tonsurans — Threads and Chains of 
Spores. X 400. (After Bizzosero.) 

At times the eruption is accompanied by severe local inflamma- 
tion and exudation of a yellowish, viscid or gelatinous secretion — kerion. 
a condition generally described as tinea kerion. 

In the treatment of ringworm of the scalp it is essential not 
only to prevent spreading of the disease from one child to the 
other, but also autoinoculation from one part of the scalp to the 

. . . , . Prevention 

other. This is best accomplished by sterilization (before and of epidemics, 
after using) of the hair clippers, scissors, combs, etc., and 
thorough scrubbing of the scalp with the tincture of green soap 
twice daily, and immediately after a haircut. 

In an epidemic at an orphan asylum comprising nearly 400 
cases of ringworm of the scalp, I found the following method of 
treatment exceedingly serviceable : — 

IJ Acidi carbolici, 

Olei petrolei aa 5i j | 65 

Tinct. iodini, I 

Olei ricini aa Biiiss I 1 10 

Olei rusci (German) q. s. ad Sxvj j 500 



604 



DISEASES OF THE SKIN. 



After clipping the hair close to the scalp this mixture is 
applied over the entire scalp — more thickly over the affected spots 
Specific — by means of a painter's brush, once a day for five successive 
of treatment, days. On the sixth day it is wiped off with a rag dipped in plain 
olive-oil; now the hair is clipped again and the scalp washed 
thoroughly but gently with green soap and a soft nailbrush, care 
being taken that all the scales and loose hair covering the scalp 




Fig. 206. — Tinea Tonsurans. (Shoemaker.) 

are removed. As a rule, no epilation is necessar)^ On the 
.seventh day the mixture is reapplied as thickly as before and 
the whole process repeated regularly for three or four successive 
weeks — the length of time depending upon the severity of the 
case. New hair will now be found to appear, and no trichophy- 
ton fungi will be discovered in the hair epilated for microscopic 
examination. 

These procedures are followed by a few days' application of a 
10-per-cent. sulphur ointment, and then by the use of the follow- 
ing preparation for about two weeks : — 



TIXEA TRICHOPHYTIXA CORPORIS. 



605 



IJ Resorcini, 

Acidi salicyl aa 3iv 

Alcoholis 3iv 

Olei ricini q. s. ad Bxvj 



16 
120 
500 



This mixture considerably hastens the growth of the hair on 
the bald spots. In cases where isolation is impracticable or impos- 
sible, as often happens in private families, this resorcin mixture 
serves as an excellent substitute to prevent spreading of the 
affection. 

Tinea tonsurans is not to be confounded with tinea favosa, a 
hair affection caused bv the Achorion Schonleinii, and character- 



Differentia- 
tion from 
tinea 
favosa. 




Fig. 207. — Achorion Schonleinii. X 400. (After Bizzozero.) 

ized by sulphur-yellow, cup-shaped crusts or scutula, penetrated 
bv a hair or two. 



TINEA TRICHOPHYTINA CORPORIS 

(Ringworm of the Body, Herpes Circinatus). 

Ringworm of the bod}^ begins as a small, scaly, circular spot 
which rapidly spreads peripherally and clears in the center, 
resembling a "ring" in shap'e. The rings frequently coalesce, 
forming serpiginous lesions. 

It is a trivial eruption and promptly yields to a few local 
applications of the tincture of iodin, white precipitate ointment 
or glacial acetic acid (applied once every other day). 



Tincture 
' of iodin. 



606 DISEASES OF THE SKIN. 



MOLLUSCUM CONTAGIOSUM. 

Contagious molluscum is not rarely met in epidemic form in 
large institutions for children. The etiologic factor of the dis- 
ease is as yet unknown. 
Wart-like The eruption appears principally upon the face, eyelids, neck 
principally and arms, and consists of discrete, semiglobular, waxy-white, 
umbilicated, small (up to a split pea) wart-like elevations, with 
sebaceous contents. 

It is a benign aftection and readily curable by ablation of the 
nodule or expression of its contents, and cauterization with tinc- 
ture of iodin or 5 per cent, salicylic acid in collodion. 



INDEX. 



Abdomen, retracted in meningitis, 
343 ; size and shape of, 39. 

Abdominal, organs, anatomy of, 36; 
pain. 40; regions, 19, Zl ; resist- 
ance, 40; tuberculosis, 369; wall, 
normal, 36; wall, congenital mal- 
formations of, 143. 

Abducens nerve, paralysis of, 289. 

Abscess, in appendicitis, 218; cere- 
bral, 252, 522; ear, 251; in coxitis, 
386 ; hepatic, 233 ; in spondylitis, 
376; retropharyngeal, 249. 

Acarus or sarcoptes scabiei, 601. 

Aceton in urine, 46. 

Achondroplasia, 504 ; differentiated 
from rachitis, 502. 

Achorion Schonleinii, 605. 

Addison's disease, 481. 

Adenie, 472. 

Adenitis, scrofulous, 370; in skin dis- 
eases, 591 ; tuberculous, ZIZ. 

Adenoids, 243; curette, 247; differen- 
tiated from laryngeal tumors, 259 ; 
operation, 247. 

Adhesio, linguae, 130; preputii, 150. 

Adipositas, 510. 

Aerocele, 133. 

.Estivoautumnal fever, 410. 

Airing, 85. 

Albinism, 132. 

Albuminuria, 46 ; cyclical or func- 
tional, 456; in nephritis, 448; 
transient, 315. 

Alimentary tract, diseases of, 185 ; 
malformations of, 136. 

Alteratives, 117. 

Amaurosis, uremic, 316, 450. 

Amaurotic family idiocv, 574, 579, 
583. 

Amebic dysentery, 334. 

Amnion navel, 144. 

Amygdalitis, 240. 

Amyloid, disease, 396 ; liver and 
spleen, 232, 233. 

Anemia, cerebral, 515; pernicious, 
475 ; pseudoleukemic, 473 : simple, 
471 ; splenic, 473. 

Angina, 240 ; Ludovici, 314. 

Aniridia, 132. 

Ankle-clonus, 56. 

Ankyloblepharon, 131. 

Ankyloglossia, 130. 



; Ankylostomiasis, 227, 228. 

j Ankylostomum duodenale, 227, 228. 

I Annulus migrans, 191. 

Anodynes, 117. 

Anopiithahuus, 130, 131. 

Anthelmintics, 119. 

Anticostive triad, 209. 

Antidiphtheritic serum, 94 ; in diph- 
theria. 303 ; in noma, 189 ; in scar- 
latinal angina, 319. 

Antimeningococcic serum, 95 ; in 
meningitis, 344. 

Antipyretics, 117. 

Antirheumatics, 117. 

Antispasmodics, 118. 

Antistreptococcic serum, in scarla- 
tina, 320. 

Antitetanic serum, 95 ; in tetanus 
neonatorum, 179. 

Anuria, 45, 460. 

Anus, absence of, 142 ; imperforate, 
141. 

Aortic, obstruction, 442; regurgita- 
! tion, 442; stenosis, congenital, 431. 

Aphthse, Bednar's, 187. 

Aphthous stomatitis, 186. 

Apoplexia neonatorum, 161. 

Appendicitis, 214, 269; acute differen- 
tiated from intussusception, 213 ; 
from psoas abscess, 381. 

Argyl-Robertson pupil, 8. 

Arnold sterilizer, 71. 

Aromatic bath, 106. 

Arteritis and phlebitis umbilicalis, 
180. 

Arthritis, gonorrheal, 419, 467; he- 
reditosyphilitic, 419 ; rheumatic, 
415; septic, 420; tuberculous, 420. 

Articular osteitis, of hip, 386; in rheu- 
matism, 415. 

Artificial, feeding, 67 ; respiration, 
165. 

Ascaris lumbricoides, 224. 

Aspersion bath, 105. 

Asphyxia neonatorum, 165. 

Aspidium (male fern), 119. 

Asthma, 279; thymicum, 484. 

Astringents, 120. 

Ataxia, diphtheritic, 301 ; hereditarv, 
537. 

Atelectasis neonatorum, 166. 

Athetosis, 521. 

(607) 



608 



INDEX. 



Athletics, 86. 

Athrepsia, 493. 

Atresia, ani, 141 ; auris, 133 ; hyme- 
nalis, 153 ; oris, 130 ; oesophagi, 
136 ; posterior nares, 132 ; pupillse, 
132 ; recti, . 141 ; urethrje, 149 ; 
vagina, 154; vulvae, 153. 

Atrophy, infantile, 493. 

Attitude of head, 5. 

Auditory meatus, absence of, 133. 

Auricular appendages, 133. 

Auscultation, of lungs, 17; of heart, 
19. 

Eabinski's sign, 57 ; in meningitis, 
338. 

Bacterial vaccines, 96. 

Bacteriuria, 49. 

Eanti's disease, 482. 

Barley water, 69. 

Barlow's disease, 506; differentiated 
from rheumatic arthritis, 420. 

Basedow's disease, 487. 

Eathing, 83. 

Baths, 104. 

Bednar's aphthse, 187. 

Eed-wetting. 461. 

Bell's palsy, 541. 

Eier's passive hyperemia. 392. 

Eiologic diagnosis and therapeutics, 
91. 

Eirth, injuries, 159; paralysis, 161. 

Bismuth mixture, 120. 

Bitter tonics, 116. 

Elack, measles, 293 ; small-pox, 326. 

Eladder, congenital malformations, 
148; stones, 460; tuberculosis of, 
370. 

Bleedine^ from navel, 174. 

Elood, diseases, 470; normal, 470. 

Blue sickness, 428. 

Bone diseases, non-tuberculous, 394; 
tuberculous, 374. 

Bothriocephalus latus, 224, 225. 
Boundaries, anterior, of lungs, 23 ; 

posterior, 24; of heart, 29. 
Bow-legs, 500. 
Brachial paralysis, 163, 164. 
Bradycardia, in influenza, 290. 

Erain, abscess, 522; abscess differen- 
tiated from tumor, 526; anemia 
515; dropsy, 516; hyperemia, 515 
localization, 514; syphilis, 403 
tuberculosis, 365 ; tumor, 524 
tumor differentiated from ab- 
scess, 523 ; from meningitis, 343. 
Bran bath, 106. 
Branchial appendages, 134. 
Eranchiogenetic cysts, 134. 



Breast, inflammation in newly born, 
184; nipples, attention to, 62; 
pump, 63. 

Breast milk, 60; analysis of, 64; 
too rich in fat, 65. 

Breathing exercises, 353. 

Bronchial glands, tuberculosis of, 
358. _ 

Bronchiectasis, 282. 

Bronchitis, 259. 

Bronchopneumonia, 259 ; differen- 
tiated from lobar pneumonia, 269. 

Bronzed skin, 481. 

Brudzinski's sign in meningitis, 337. 

Buhl's disease, 182. 

Buttermilk, 79. 

Calculi, renal, 454; vesical, 460. 

Calmette's tuberculin reaction, 97. 

Calmuck type of idiocy, 577. 

Cancrum oris, 187. 

Capacity of infantile stomach, 77. 

Capillary bronchitis, 259. 

Caput succedaneum, 159 ; differen- 
tiated from cephalhematoma, 160. 

Cardiac cirrhosis of liver, 231. 

Care of, the eyes, 176; teeth, 354; 
umbilicus, 173. 

Care of the newly born, 82. 

Caries of vertebral column, 376. 

Carpal bones, deficiency in idiots, 
580, 582. 

Castor-oil mixture, 119. 

Casts in urine, 47. 

Cataract, 132. 

Cathartics, 119. 

Caudal formations, 157. 

Central, birth-palsy, 161 ; pneumonia, 
265. 

Cephalhematoma, 159. 

Cephalocele, 126 ; differentiated from 
cephalhematoma, 160. 

Cerebral, abscess, 252, 522; convul- 
sions differentiated from eclamp- 
sia, 555 ; facial paralysis differen- 
tiated from peripheral facial palsy, 
542: hemorrhase, 161, 518; hemor- 
rhage differentiated from embol- 
ism, 518; paralysis, 512; paralysis 
differentiated from hysterical par- 
alysis, 587. 

Cerebrospinal, fluid, 340, 341 ; menin- 
gitis, 335 ; meningitis dift'eren- 
tiated from typhoid, 331. 

Cervical rib, 135, 381. 

Chafing of the skin (intertrigo), 595. 

Chapin's milk dipper, 70. 

Cheiloschisis, 128. 

Chest, abnormal shape, 20. 

Chicken-breast, 498. 

Chicken-pox, 321. 



IXDEX. 



609 



Child-crowing, 133. 
Chloroma differentiated from scor- 
butus, 508. 
Chlorosis, 471. 

Choked disc (optic neuritis), 525. 
Cholera infantum, 195. 
Chondrodystrophia foetalis, 504. 
Chorea, 563 ; magna, 588 ; rhythmica, 

588; electrica, 567. 
Choroidal tubercles, 366. 
Chvostek's phenomenon, 560. 
Circular insanity. 586. 
Circumcision, 150. 

Circumference, of chest, 20; head, 4. 
Cirrhosis of liver, 231 ; differentiated 

from tuberculous peritonitis, 368. 
Cleft, bladder, 148 ; face, 128 ; palate, 

128; vertebral column, 51. 
Climatotherapv, 114. 
Clothing, 84. ^ 
Clubfoot, 158. 
Club-shaped fingers, in heart disease, 

429. 
Coccvgeal tumors, 156. 
Cold,' effects of, 103; packs, 103; 

sponging, 103. 
Cod-liver oil mixture. 117. 
Colic, intestinal, 204. 
Colicystitis, 455, 458. 
Colitis, 195. _ 
Coloboma iridis, 132. 
Collapse of lungs, congenital, 166. 
Colon, congenital dilatation and 

hypertroph}', 139. 
Colostrum, 63. 
Communicable diseases, 287. 
Compresses, Priessnitz's, 104. 
Condensed milk, 78. 
Condyloma, S3'philitic, 400. 
Conjunctiva, tuberculin test of (Cal- 

mette), 97. 
Constipation, 42, 206 ; electricitv in, 

110. 
Consumption, hasty, 356. 
Contractures of extremities, 52. 
Convulsions, 554. 
Cor bovinum, 440. 
Cord, umbilical, care of, 173. 
Corvza, 236. 
Cough, character of, 27. 
Cows' milk, approximate composition 

of, 68; care of, 71; feeding, 68; 

substitutes, 11 . 
Coxa vara, its differentiation from 

coxitis, 389. 
Coxitis tuberculosa, 386 ; differen- 
tiated from rheumatism, 418. 
Crab-louse, 601. 
Cranial, bones, 5 ; circumference, 4 ; 

sutures, 5. 
Cream in top-milk, 69. 



Crede's method, 176, 466. 

Creeping, 86 ; pen, 86. 

Creosote in tuberculosis, 364. 

Cretinism, 488; dift'erentiated from 
rachitis, 502; idiocy, 574, 577, 578, 
579 ; endemic and sporadic, 488. 

Croup, 253 ; diphtheritic, 298 ; differ- 
entiated from laryngeal tumors, 
259; false, 254; spasmodic, 254. 

Crusta lactea, 591. 

Cryptophthalmus, 131. 

Cryptorchidism, 151. 

Curvatures of. extremities, 51 ; spine, 
50. 

Cutaneous tuberculin test, 97. 

Cyanosis, congenital, 428. 

Cyclic albuminuria, 456. 

C5^sticerci in the brain, 527. 

Cvstitis, 458. 

Cvtodiagnosis of cerebrospinal fluid, 
' 341. 

Dactvlitis. svphilitic, 407 ; tubercu- 
lous, 393.' 

Deaf-mutism, 573. 

Deafness, syphilitic, 405. 

Death, thymus, 484. 

Dementia, acute, 586 ; paralvtic. 586. 

Dentitio difficilis, 189. 

Dermatitis exfoliativa neonatorum, 
178. 

Dextrocardia, 432. 

Diabetes, insipidus, 509 : mellitus, 
508. 

Diagnostic lines of the thorax, 22. 

Diaphoretics, 119. 

Diarrhea, 42 ; and vomiting, 195. 

Diastasis recti abdominis, 143. 

Diazo-reaction in typhoid, 329. 

Dietarv, after weaning, 80. 

Difficult teething, 189. 

Disrestants, 116. 

Diluents, 68. 

Diphtheria, 241, 296; antitoxin, 94, 
189, 303, 319; bacilli. 297; differen- 
tiated from tonsillitis, 242; in 
scarlatina, 314; laryngeal, 310; 
pharyngeal, 309 ; vulvae, 468 ; diph- 
theritic paralysis, 300; paralysis 
differentiated from poliomyehtis, 
535. 

Diplegia, 512. 

Diplopia, 9. 

Discharges, rectal. 50; vulvovaginal, 
49. 

Disinfection, 88, 90; solutions, 90^^ 

Dislocation of hip, congenital, 157; 
dift'erentiated from coxitis, 390. 

Disseminated sclerosis, 538. 

Diuretics. 119. 

Diverticulum, Meckel's, 147. 



39 



610 



INDEX. 



Double-jointed, 501. 

Dry middle-ear disease, 251. 

Duchenne-Erb paralysis, 163, 164. 

Duck gait, 157. 

Ductless glands, diseases of, 470. 

Ductus, arteriosus Botalli, persistence 

of, 430; omphalomesentericus, 

196. 
Duke's disease, 321. 
Dysentery, 333. 
Dyspepsia, 195. 
Dystrophia muscularis, 547. 
Dysuria, 460. 

Ear, affections, 251 ; appendages, 133. 

Eclampsia, infantile, 554; differen- 
tiated from meningitis, 342. 

Ecthyma, 599. 

Ectopia, cordis, 432; vesicae, 148; 
viscerum, 144. 

Eczema, 591. 

Edema, of eyelids, 7; glottidis, 258; 
scleredema, 172. 

Effileurage, 112. 

Ehrlich and Hata preparation in 
syphilis, 409. 

Electricity, 109. 

Embolism of cerebral arteries, 518. 

Emetics, 119. 

Emphysema, cutus (see Pneumohypo- 
derma), 286; pulmonum, 282; sur- 
gical, 286. 

Empyema, 276; necessitatis, 277. 

Encephalitis, 522, 

Encephalocele, 127. 

Endocarditis, acute, 436; chronic, 
439 ; malignant, 438 ; in rheuma- 
tism, 417; in scarlatina, 315. 

English disease (see Rachitis), 496. 

Enteralgia, 204. 

Enteric fever, 328. 

Enteritis, 195. 

Enteroclysis, 108. 

Enterocolitis, 195. 

Enuresis, 461 ; electricity in, 110. 

Eosinophilia in asthma, 280. 

Epilepsy, 549; nutans, 551; procur- 
siva, 552; differentiated from 
eclampsia, 555 ; from hystero- 
epilepsy, 589. 

Epiphyseolysis, in osteomyelitis, 396 ; 
rachitic, 500. 

Epiphysitis, syphilitic, 419. 

Epispadias, 149. 

Epistaxis, 11, 237. 

Epithelial pearls, 187 ; differentiated 
from ulcerative stomatitis, 187. 

Epitrochlear glands, enlarged in syph- 
ilis, 401. 

Erb's, paralysis, 163; sign of tetany, 
560. 



Eruptive fevers, differential table, 
327. 

Erysipelas neonatorum, 181. 

Erythema nodosum, 423. 

Escherich's incubator room, 170. 

Esophagitis, 191. 

Esophagus, atresia of, 136; diseases 
of, 191. 

Eustachian tube, catarrh of, 251. 

Examination of patient, 1. 

Exanthemata, differential table, 327. 

Exercise, 85; danger in overindul- 
gence of, 86. 

Exomphalos, 144. 

Exostoses, multiple, 426. 

Expectorants, 120. 

Expectoration, character of, 28, 29. 

Exstrophy of bladder, 148. 

Extremities, examination of, 51 ; 
shortness of, 51; tumefactions of, 
51. 

Eye, normal fundus of, 583 ; in" the 
newly born, care of, 176. 

Eyeballs, semeiology of, 8. 

Eyelids, semeiology of, 7. 

Face, semeiology of, 6. 

Facial, appearance of, in diagnosis, 

6; hemiatrophy, progressive, 544; 

hue, 7 ; paralysis, 162, 534, 541 ; 

paralysis, electricity in. 111. 
Family, history, 1 ; idiocy, 583. 
Faradic current, 110. 
Fat, breast milk, 65 ; diarrhea, 202 ; 

percentage in top-milk, 69. 
Fatty, degeneration in the new-born, 

acute, 182; liver, 232. 
Febris rubra, 311. 
Fede's disease, 190. 
Feeble vitality of the newly born, 165 ; 

management, 168. 
Feeding, of infants, 60, 80, 81, 82; 

scheme, 76. 
Fever charts, of endocarditis maligna. 

438; influenza, 288; intermittent 

malarial, 411; pneumonia, 267, 

268 ; tuberculous meningitis, 337 ; 

typhoid, 329. 
Fever, glandular, 241; malarial, 410; 

rheumatic, 415; scarlatinal, 311; 

typhoid, 328. 
Filatov-Koplik spots, 292. 
Fissure, of bladder, 148; and fistulas 

of ear, 133 ; vesicae umbilicalis, 

147. 
Fistula, coli congenita, 134; ani dif- 
ferentiated from proctitis, 204. 
Fits, epileptic, 549. 
Flaccid paralysis, 52. 
Flatulence, colic, 204. 
Flaxseed poultice, 263. 



INDEX. 



()11 



Flexiier's serum in meningitis, 95. 
344. 

Floating kidney, 148. 

Floor of month, abnormalities of, 14. 

Fetal skull, 3. 

Fcetor ex ore, 12. 

Fontanelles, 5. 

Foods, infants', 79. 

Foot-drop, 530. 

Foramen ovale, persistence of, 429. 

Foreign bodies, in ear, 252; differen- 
tiated from otitis media, 252; in 
larynx, 259; in nose, 238. 

Formaldehyd-potassium permangan- 
ate fumigation, 91. 

Fourth disease, 321. 

Friction in massage, 113. 

Friedreich's ataxia, 538. 

Fumigation, 90. 

Functional, diseases in the newly 
born, 183 ; heart murmurs, 443. 

Funnel-shaped chest, in adenoids, 
245 ; congenital, 135. 

Furunculosis of the ear differen- 
tiated from otitis media, 252. 

Gait, semeiology of, 56. 

Galvanic current, 109. 

Gangrene, of genitalia, 468; lungs, 
283 ; mouth, 187 ; skin in vari- 
cella, 322. 

Gastralgia, 204. 

Gastric sedatives, 120. 

Gastritis, 195. 

Gastroenterocolitis, acute, 195;' 
chronic, 200 ; differentiated from 
typhoid, 331. 

Gavage, 344. 

Genitalia, 49; congenital malforma- 
tions, 148 ; diseases, 463 ; tuber- 
culosis, 370. 

Genu, valgum, 500 ; varum, 500. 

Geographic tongue, 191. 

German measles, 295. 

Gibbus (see Kyphosis), 379. 

Glands, bronchial, tuberculosis of, 
358. 

Glandular fever differentiated from 
tonsillitis, 241. 

Glossitis, 191. 

Glottis, edema of, 258; spasm, 281, 
562. 

Glycosuria, 45, 508. 

Goiter, 486 ; cystic, 487 ; exophthal- 
mic, 487. 

Gonorrheal, arthritis, 419, 467 ; differ- 
entiated from rheumatic arthritis, 
419; ophthalmia, 175, 466; proc- 
titis, 466; vulvovaginitis, 463. 

Granuloma of umbilicus, 174. 

Green, sickness, 471 ; tumor, 508. 



Grip, 241. 

Grocco's sign in pleurisy, 274. 

Growing pain, 417, 445. 

Gumma, subcutaneous, 407. 

Gums, semeiology of, 12; bleeding 

from, 480, 505. 
Growth, sublingual, 190. 

Habit spasm, 567. 

Haemorrhea, acquisita, 181, 478; con- 
genita (see Hemophilia), 477. 

Half-cretin, 490. 

Hand-trident in achondroplasia, 504. 

Hardening, 85. 

Hare-lip, 128. 

Head, attitude of, 5 ; circumference, 
4; drop, 531; lice, 600; nodding, 
567 ; semeiology, 4. 

Headache, 568 ; in brain tumor, 524. 

Health resorts, 114. 

Hearing, defects of, 10. 

Heart, apex, 32; beat, 32; boundaries, 
29; dilatation, 440; diseases, ac- 
quired, 433 ; diseases, congenital, 
428; dullness, 30, 31, 34; mur- 
murs, 33 ; normal, 29 ; hyper- 
trophy, 440 ; paralysis in diph- 
theria, 300; percussion, 19; seda- 
tives, 118; skiagram, 29; sounds, 
33 ; topograph}^ 30 ; transposition, 
432; valves, 34. 

Heat, effects of, 103. 

Hebephrenia, 585. 

Hectic fever, 361. 

Height, 58. 

Hematoma of sternomastoid, 160. 

Hematuria, semeiology of, 48. 

tiemianopsia, semeiology of, 9. 

Hemiatrophia faciei, 544. 

Hemichorea, 565, 

Hemicrania, 568. 

Hemiplegia, 512; in diphtheria, 301; 
double, 512; spastica infantilis, 
520. 

Hemoglobinuria, 455 ; with icterus, 
182. 

Hemophilia (see Hsemorrhea\ 477, 
480 ; differentiated from purpura, 
480 ; transitory, 478. 

Hemothorax, 283. 

Hemoptvsis, 361. 

Hemorrhage, cerebral, 161, 518; 
cutaneous, 480 ; intestinal, 333 ; 
intracranial, 518; meningeal, 518; 
nasal, 237 ; pulmonary, 361 ; rectal, 
203; renal, 448; spinal, 528; um- 
bilical, 174. ■ 

Hemorrhoids differentiated from 
proctitis, 204. 

Henoch's purpura, 480. 

Hepatitis in syphilis, 402. 



612 



INDEX. 



Heredoataxie cerebelleuse, 537. 

Hernise, 41 ; cerebral, 126 ; inguinal, 
dfferentiated from psoas abscess, 
381; spinal, 154; umbilical, 144. 

Herpes, circinatus, 605 ; tonsurans, 
603 ; zoster, 597. 

Hip, congenital dislocation of, 157; 
joint disease, 386. 

Hives, 594. 

Hirschsprung's disease, 139. 

History of patient, 1. 

Hodgkin's disease, 472. 

Holt's milk set, 64. 

Home-made liquid capsules, 115. 

Home modification of cows' milk, IZ. 

Hookworm disease, 227. 

Horseshoe kidney, 148. 

Hot baths, 105. 

Hutchinson's, teeth, 405 ; triad in 
syphilis, 405. 

Hydatid cyst of liver, 234. 

Hydrocele, 152. 

Hydrocephalic, cry in meningitis, 
343; idocy, 574, 575, 578. 

Hydrocephalocele, 127. 

Hydrocephaloid, 197, 515. 

Hydrocephalus, acquired, 516; chron- 
ic, 365 ; congenital, 124 ; false, 
516; differentiated from rachitis, 
503. 

Hydronephrosis, 148. 

Hydrotherapy, 102. 

Hydrothorax, 277 ; differentiated from 
pleurisy, 277. 

Hygiene and sanitation, 82. 

Hygroma, cysticum, 134 ; differen- 
tiated from goiter, 487; sacral, 
156. 

Hvmen, imperforate, 153. 

Hyperemia, cerebral, 515; passive, 
Bier's method of treatment, 392. 

Hyperidrosis in rachitis, 496. 

Hypertrophic, cirrhosis of liver, 231; 
pyloric stenosis, 136. 

Hypertrophy, of heart, 440 ; differen- 
tiated from pericarditis with 
effusion, 435 ; pseudo, muscular, 
547; of tonsils, 242. 

H5^pnotics, 117. 

Hypodermoclysis, 109. 

Hypospadias, 149. 

Hysteria, 587; electricity in. 111. 

Hysterical contracture differentiated 

from coxitis, 390. 
Hysteroepilepsy, 589. 

Icterus, catarrhal, 230 ; epidemic, 230 ; 
with hemoglobinuria, 182 ; neona- 
torum, catarrhal, 183. 



Idiocy, amaurotic, 583; different 
varieties, and allied mental defi- 
ciencies, 570. 

Idiotic face in adenoids, 244. 

Ileocolitis, epidemic, 333. 

Imbecility, 581, 585. 

Immunity, 91. 

Immunization, 91 ; in diphtheria, 302. 

Imperforate, anus, 141 ; hymen, 153. 

Impetigo contagiosa, 599. 

Incubators, 169, 170. 

Infantile, paralysis, 529; muscular 
atrophy, 548. 

Infantilism, 575, 577, 581 ; syphilitic, 
407. 

Infants' stools, semeiology of, 43. 

Infant, feeding, 60, 80; foods, 79. 

Infarct, uric acid, in the newborn, 
183. 

Influenza, 287 ; differentiated from 
tonsillitis, 241 ; from typhoid, 331. 

Inherent strength, 59. 

Inland resorts, 114. 

Inorganic murmurs of heart, 443. 

Insanity, circular, 586. 

Intermittent fever, 410. 

Intestines, Z6; catarrh (see Gastro- 
enterocolitis), 195; diseases of, 
195 ; invagination or intussuscep- 
tion, 212 ; stenosis, 139 ; differen- 
tiated from strangulation, 213 ; 
syphilis, 403 ; tuberculosis, 369 ; 
worms, 222. 

Intubation, 305 ; accidents during, 308. 

Intussusception, 212 ; differentiated 
from proctitis, 204; from prolap- 
sus recti, 210. 

Invagination, intestinal, 212. 

Iridoschisma, 132. 

Iridoschisme, 132. 

Irrigations, 108. 

Ischuria, 460. 

Isolation, 88. 

Itch, 601. 

Jacksonian or cortical epilepsy, 550. 
Jaundice, catarrhal, 230; with hemo- 
globinuria, 182; neonatorum, 183. 
Joints, tuberculosis of, 374. 
Juvenile muscular atrophy, 548. 

Katatonia, 585. 

Keratitis, syphilitic, 405. 

Kernig's sign, 57, 338. 

Kidnev, diseases, 447; malformations, 

148; normal, 39; stones, 454; 

topography of, 39; tuberculosis, 

370; tumors, 457. 
Knee-jerk, 56. 
Knee-joint disease, 391. 
Knock-knees, rachitic, 500. 



INDEX. 



()i;] 



Koch's tubercle bacillus. 
Koplik-Filatov spots, 15 

292. 
K^-phosis, 381, 498. 



352. 
in measles, 



Labium leporinum, 128. 

Laboratory milk, 12. 

Landry's paralysis differentiated from 
poliomyelitis, 535 ; from polyneu- 
ritis, 544. 

Laryngeal, diphtheria, 255, 298 ; syph- 
ilis, 257 ; tuberculosis, 257 ; tu- 
mors, 259. 

Laryngismus stridulus, 254. 

Laryngitis, acute, 253 ; catarrhal, 254 ; 
chronic, 256 ; diphtheritic, mem- 
branous, 255, 298; membranous, 
. non-diphtheritic, 255 ; spasmodic, 
254; stridula, 254. 

Laryngocele, 133. 

Laryngospasmus, 562. 

Larynx, foreign bodies in, 259; mal- 
formations of, 133. 

Lateral curvatures of spine, 382. 

Lavage, 107 ; contraindications to, 
107. 

Laxatives, 119. 

Leichtenstern's sign in meningitis, 
338. 

Length of child, 57. 

Leucocythemia, 474. 

Leukemia, 474 ; lymphatic, 475 ; 
splenic, 475. 

Lice, body and head, 600. 

Lichen strophulus, 598. 

Lien mobilis, 481. 

Lingua geograohica, 191. 

Lipomatosis, 510. 

Lins, semeiology, 11. 

Little's disease, 539. 

Liver, abscess, 233 ; abscess differen- 
tiated from pleurisy, 277 ; amy- 
loid, 232; atrophy, 232; cirrhosis, 
231; diseases of, 230; normal, 2)7; 
sugar-coated, 231 ; topography, 38, 
39; tumors, 234. 

Lobar pneumonia, 265. 

Lobular pneumonia (see Broncho- 
pneumonia), 259. 

Lordosis, 384 ; compensatory, 389. 

Lumbar puncture, 339; in meningitis, 
339; in scarlatinal uremia, 319. 

Lungs, auscultation of, 17 ; diseases 
of, 259; normal, 21; percussion 
of, 18; topography, 21. 

Luschka's tonsil, 243. 

Luxatio coxae congenita, 157. 

Lymphadenitis, tuberculous, ZIZ. 

Lymphadenoma, 472. 

Lymphangioma cysticum, 134. 

Lymphatic glands, semeiology, 16. 



McEvven sign in meningitis, 339. 

Macroglossia, 130. 

Macrostoma, 128. 

Malaria, 410; chronic, 413; differen- 
tiated from miliary tuberculosis, 
357; from typhoid, 331. 

Male fern (aspidium), 119. 

Malt bath, 106. 

Malt soup, n ; in marasmus, 495. 

Mammarv glands, inflammation of, in 
the newborn, 184. 

Mania, 586. 

Marasmus, 493 ; differentiated from 
miliary tuberculosis, 358. 

Massage, 112; contraindications to, 
112; indications of, 112. 

Mastitis, complicating mumps, 346 ; 
neonatorum, 184. 

Mastoiditis, 251. 

Masturbation, 468. 

Materia medica, 102. 

Maternal nursing, 62 ; contraindica- 
tions to, 66. 

Measles, 291. 

Meckel's diverticulum, 147. 

Meconium, absence of, 142, 

Medicated baths, 106. 

Medicines, mode of administration, 
121. 

Megacolon congenitum, 139. 

Melancholia, 586. 

Melena neonatorum, 181. 

Meloschisis, 128. 

Meningeal hemorrhage, 518. 

Meningitic idiocy, 574, 577. 

Meningitis, acute, 335 ; acute, differ- 
entiated from encephalitis, 523 ; 
antitoxin, 95 ; spinal, 528 ; tuber- 
culous, differentiated from other 
forms, 342. 

Meningocele, 127; spinalis, 154. 

Menstruatio prascox, 469. 

Mental, diseases, 570; stigmata of 
degeneration, 572. 

Mercurial bath, 106. 

Mesocardia, 432. 

Metabolism, disturbance of, 493. 

Microcephalic idiocy, 574, 575, 579. 

Microcephalus, 123. 

Micromelia, 504. 

Microphthalmus, 131. 

Microscopy of human milk, 61. 

Microstoma, 130. 

Migraine, 568. 

Miliaria, 598. 

Miliary tuberculosis, 356; differen- 
tiated from lobar pneumonia, 270 ; 
from typhoid, 331 ; skiagram of 
lungs, 357. 



614 



INDEX. 



Milk, cows', 68; formulse, 74; human, 
60; modified, 72; peptonized, 79; 
top, 69. 

Mineral acids, 117. 

Miniature brain, 123. 

Mitral heart disease, 441. 

Moeller-Barlow's disease, 505. 

Molluscum contagiosum, 606. 

Mongolian idiocy, 574, 576, 579. 

Monoplegia, 513. 

Monorchidism, 151. 

Morbilli, 291. 

Morbus, coeruleus, 428; coxarius, 386. 

Moro's tuberculin test, 98. 

Mosquitoes as malaria carriers, 413. 

Mountain resorts, 114. 

Mouth, semeiology, 11; wash, 188. 

Mumps, epidemic, 345. 

Muscular, atrophies, hereditary, 545 ; 
contractures, 52 : rheumatism, 417 ; 
weakness, 52. 

Mustard, bath, 106; water compresses 
in pneumonia, 271. 

Myelitis, 536 ; differentiated from 
poliomyelitis, 535. 

Myelocystocele spinalis, 154. 

Myelomeningocele spinalis, 154. 

Myocarditis, 433. 

Myositis, 425 ; ossificans, 427 ; scar- 
latinal, 314. 

Myotonia congenita, 549. 

Myxidiocy, 488. 

Nares, posterior, atresia of, 132. 

Nasal, discharge, 10 ; hemorrhage, 
237 ; tuberculin test, 97. 

Navel, diseases of (see Umbilicus), 
172. 

Neck, malformations of, 134; in 
meningitis, 2)?)7 ; semeiology, 16. 

Nephritis, acute, 447; chronic, 452, 
diphtheritic, 300; parotitic, 450; 
scarlatinal, 346 ; varicellosa, 322. 

Nephrolithiasis, 454. 

Neuralgia, enteric (see Colic), 204. 

Nerve diseases, 512. 

Nettle rash, 594. 

Neuritis, multiple, 543 ; multiple, 
diphtheritic, 301. 

Newly born, care of, 82; diseases of, 
_ 165. 

Night, sweats, 361 ; terrors, 569. 

Noguchi-Wassermann test in syph- 
ilis, 98. _ _ 

Noma faciei, 187 ; in measles, 294 ; 
in typhoid, 330; in scarlatina, 316; 
noma vulvae, 468. 

Nose, bleeding from, 237 ; malforma- 
tions, 132; semeiology of, 10; sad- 
dle-shaped. 400, 407; throat and 
ear diseases, 236. 



Nuclear, facial paralysis, differen- 
tiated from peripheral, 543. 
Nursery, 87. 
Nursing, time for, 63. 
Nutrition, 60. 
INystagmus, semeiology, 8. 

Oatmeal water, 69. 

Obesity, 510. 

Obstetric, brachial paralysis, 162, 163 ; 
facial paralysis, 161. 

O'Dwyer's intubation set, 305. 

Oliguria, semeiology, 45. 

Omphalitis, 172. 

Omphalocele, 144. 

Omphalorrhagia, 174. 

Onanism, 468. 

Onychitis, 409. 

Ophthalmoblennorrhea neonatorum, 
175. 

Ophthalmia, gonorrheal, 466; puru- 
lent, 175 ; strumous, 372. 

Ooisthotonos in meningitis, 2)27. 

Opsonin, 96; opsonic index, 96. 

Optic neuritis, 525; in amaurotic 
idiocy, 584; in meningitis, 338. 

Oral cavity, examination of, 12. 

Organotherapy, 121. 

Orchitis in mumps, 346. 

Orthotic albuminuria, 456. 

Osteochondritis, syphilitic, 402. 

Osteogenesis imperfecta differen- 
tiated from rachitis, 503. 

Osteitis, 394. 

Osteomyelitis, 420 ; differentiated 
from coxitis, 390 ; from rheuma- 
tism, 418 ; from scorbutus, 508 ; 
non-tuberculous, 394; of radius, 
397; tibia, 395. 

Osteoperiostitis, 406. 

Otitis, double, differentiated from 
meningitis, 342 ; externa, 252 ; 
media, 250 ; in mumps, 346 ; in 
scarlatina, 318. 

Otorrhea, bilateral, in scrofulosis, 372. 

Oxyuris vermicularis, 222. 

Ozena, 237; syphilitic, 399. 

Pain in chest on pressure, semei- 
ology, 21. 

Pack, cold, 103. 

Palatable medication, 115. 

Palate, semeiology of, 14. 

Palatoschisis, 128. 

Palatum fissum, 128. 

Pancreas disease in syphilis, 402. 

Papilloma, laryngeal, 259. 

Paralysis, brachial, 163 ; cerebral, 
512; crossed, 512; diphtheritic, 
300 ; extremities, 53 ; facial, 162, 
541 ; muscular, 54 ; pseudobulbar, 
513; spastic, 520; spinal, 529. 



INDEX. 



611 



Paralytic, dementia, 586; idiocy, 580; 

scoliosis, 385. 
Paramyoclonus, 567. 
Paraplegia, in m3^elitis, 536 ; in dis- 
seminated sclerosis, 538. 
Parasites, intestinal, 222. 
Parasituria, semeiology, 49. 
Parasyphilis, 404. 
Parathyroid gland substance, 121. 
Parotitis, epidemic, 345 ; secondary, 

191. 
Parrot's nodes in syphilis, 402. 
Passive hyperemia, Bier's treatment, 

392. 
Pasteurization of cows' milk, 72. 
Pavor nocturnus, 569. 
Pectus carinatum, rachitic, 498. 
Pearls, epithelial, 187. 
Pedatrophy. 493. 
Pediculosis, capitis, 600; corporis, 600; 

pubis, 601. 
Peliosis rheumatica, 423, 479; differ- 
entiated from scorbutus, 507. 
Pemphigus, neonatorum, 177 ; syph- 
iliticus, 167, 401 ; differentiated 
from simple pemphigus, 177. 
Peptonized milk, 79. 
Peptonuria, semeiologv, 49. 
Percussion, of heart, 19; of lungs, 18; 

resonance, 26. 
Percutaneous tuberculin test, 98. 
Pericarditis. 434; differentiated from 
endocarditis, 439; from pleurisy, 
277. 
Periosteal reflex, semeiolog>^ 57. 
Periostitis, 394. 
Peripheral, birth paralysis, 162 ; facial 

oaralysis, 541. 
Perisplenitis in syphilis, 402. 
Peristalsis, intestinal, visible, 40. 
Peritonitis, acuta, 221 ; differentiated 
from intussusception, 213 ; tuber- 
culous, 366. 
Peritonsillar abscess, 240. 
Perityphlitis, 214. 
Pernicious anemia, 475. 
Persoiration excessive in rubella, 

296. _ 
Pertussis, 347. 
Petrissage, 113. 

Pharyngitis, acute, 239; chronic, 239. 
Phimosis, 150. 

Phthisis pulmonum, 358; differen- 
tiated from bronchiectasis, 282. 
Physical, examination, 3 ; stigmata of 

degeneration, 575. 
Pick's disease, 231. 
Pigeon-breast, in adenoids, 245; in 

rachitis, 498. 
Pinworms, 222. 
Pituitary gland, extract, 121. 



Plaques muqueuses, 399. 
Plasmodium malariae, 410. 
Pleurisy, 273 ; chylous, 277 ; dry, 273 ; 
differentiated from liver abscess, 
234; from pneumonia, 269; with 
effusion, 274; hemorrhagic, 276; 
serous, 275 ; tuberculous, 275, 276. 

Pleuritis, 273. 
Pleuropneumonia, 268. 

Pneumococci, 266. 

Pneumohypoderma (emphysema cu- 
tis), 286; in measles, 293. 

Pneumonia, 265 ; alba, 167 ; aspiration 
pneumonia, 300; broncho, 259; 
central, 267 ; chronic, 272 ; differ- 
entiated from meningitis, 342; 
from miliary tuberculosis, 357 ; 
from otitis media, 252; from pleu- 
risy, 278; from typhoid, 331; 
fibroid, 272; lobar, 265; unre- 
solved, 268, 272; wandering, 265. 

Pneumonitis, 265. 

Pneumothorax, 283. 

Polioencephalitis, acute, 520 ; dift'er- 
entiated from poliomyelitis, 535. 

Poliomyelitis, 529 ; differentiated from 
cerebral paralysis, 513; from 
polioencephalitis, 521 _; from poly- 
neuritis, 544; electricity in. 111. 

Polyarthritis, 415. 

Polymyositis, 425. 

Polyneuritis, 543. 

Polyuria, semeiologv, 44; in diabetes, 
509. 

Porencephalia, 514. 

Pot-belly, in rachitis, 501. 

Pott's disease, 376. 

Poultice of flaxseed meal, 263. 

Precocity, 469. 

Premature birth, 167. 

Prepuce, malformations of, 149. 

Pressure paralysis in spondylitis, 
378. 

Prevention and control of disease, 
59. 

Prickly heat, 598. 

Priessnitz's compresses, 104. 

Proctitis, 203; gonorrheal, 466. 

Progressive muscular atrophy and 
dystrophy, 547 : differentiated from 
poliomyelitis, 535. 

Prolapsus ani et recti, 210. 

Proprietary infant foods, 79. 

Prurigo, 594. 

Pseudofurunculosis, 599. 

Pseudohypertrophic paralysis, 547. 

Pseudohypertrophy, 548. 

Pseudoleukemia infantum, splenica, 
437; lymphatica, 472. 

Pseudomeningocele, 127. 



616 



INDEX. 



Pseudoparalysis, rachitic, 501 ; syph- 
ilitic, 402. 

Pseiidotetanus, 562. 

Psoas abscess, 381. 

Psoriasis, 595. 

Pulmonary edema, differentiated from 
asthma, 281. 

Pulmonary valve, affections of, 431, 
442, 443. 

Pulsation of arteries and veins of 
neck, semeiology, 17. 

Pulse, semeiology, 35 ; rate, 32 ; res- 
piration ratio, 32. 

Pupils, semeiology, 8. 

Purgatives, 119. 

Purpura, fulminans, 480 ; hemor- 
rhagica, 420, 479; differentiated 
from scorbutus, 507; rheumatica, 
423 ; simplex, 479 ; vaccinatoria, 
93. 

Purulent ophthalmia, 175. 

Pyelitis, 454. 

Pyelonephritis, 454. 

Pyelonephrosis, 454. 

Pyloric stenosis, 136. 

Pylorospasm, 137. 

Pyopneumothorax, 283. 

Pyothorax, 276. 

Pyemia, differentiated from inter- 
mittent fever, 412. 

Pyuria, semeiology, 48. 

Quantity of food for infant feeding, 

75. 
Quarantine, 88. 
Quinine, specific in malaria, 414; in 

pertussis, 350. 
Quinsy, 240. 

Rachitis, 496; acute, 505; differen- 
tiated from scorbutus, 508; fetal, | 
504; kyphosis, differentiated from 
spondylitis, 381 ; rosary, 497 ; 
scoliosis, 384. 

Ranula, 190. 

Rectal, discharges, semeiology, 50 ; 
malformations, 141 ; polypus, dif- 
ferentiated from prolapsus recti, 
210; prolapse, 210. 

Reflexes of tendons, semeiology, 56. 

Regions, abdominal and thoracic, Zl ; 
of spine, 19. 

Remittent, jestivo-autumnal fever, 
412 ; differentiated from menin- 
gitis, 342. 

Ren morbilis, 148. 

Renal, calculi, 454; hemorrhage, 448. 

Resorcin-alcohol, in scarlatinal an- 
gina, 318. 

Respiration, semeiology, 23. 

Respiratory, diseases, 235 ; sounds, 25. 



Retained intubation tube, 308. 
Retropharyngeal abscess, 249, 259, 

381. 
Revaccination, 94. 
Rheumatism, acute, 415; chronic, 422; 

differentiated from coxitis, 390; 

from poliomyelitis, 535 ; from 

scorbutus, 507; electricity in, 111; 

muscular, 417; nodosus, 423; scar- 
latinal, 314. 
Rhinitis, acute, 236; chronic, 237; 

diphtheritic, 298; syphilitic, 399. 
Ribs, malformations of, 135 ; cervical, 

135, 381. 
Rice-water, 69. 
Rickets, 496. 
Riga's disease, 190. 
Rigidity of the limbs, congenital, 

539. 
Ringworm, of body, 605 ; of scalp, 

603. 
Risus sardonicus, 180. 
Roseola, epidemic, 295. 
Rotheln, 295. 
Roundworms, 224. 
Rubella, 295. 
Rubeola, 291. 

Saber-shaped deformity of tibia, ra- 
chitic, 500; in syphilis, 406. 

Sacral tumors, congenital, 156. 

Saddle, back, 548 ; nose, in syphilis, 
400, 407. 

Saint Vitus's dance, 563. 

Salaamkrampf, 551. 

Salicylates, specific, in rheumatism, 
421. 

Saline injections, 108. 

Saliva, semeiology, 16. 

Salivary glands, diseases of, 190. 

Salivation, 190. 

Sarcoma, of femur, 390 ; differen- 
tiated from coxitis, 390 ; of kid- 
ney, 457; of thymus gland, 484. 

Sarcomphalos, 147, 174. 

Sarcoptes scabiei, 602. 

Scabies, 601. 

Scapula, abnormal position of, 21. 

Scarlatina, 311; angina, 313; differen- 
tiated from diphtheria, 310; from 
tonsillitis, 242; from incipient 
pneumonia with erythema, 269; 
malignant, 317; nephritis in, 315; 
otitis in, 318; rheumatism in, 314. 

Scheme for infant feeding, 76. 

Schoenlein's disease, 424. 

Scissors gait, 539. 

Scleredema neonatorum, 172. 

Sclerema, adiposum, 171 ; serosum, 
172; differentiated from sclere- 
dema, 172. 



INDEX. 



617 



Sclerosis, multiple, disseminated, 538. 

Scoliosis, 382,_384, 498. 

Scorbutus, 505 ; differentiated from 

poliomyelitis, 535 ; from purpura 

haemorrhagica, 480 ; from rheu- 
matic arthritis, 420. 
Scrofulosis (see Tuberculosis), 370. 
Scrotum, absence of, 141 ; tumefac- 
tions of, 49. 
Scur\7- (see Scorbutus), 505. 
Sea-salt baths, 106. 
Seashore resorts, 114. 
Seborrhoea capitis, 591. 
Selection of wet-nurse, 66. 
Sepsis neonatorum, 172. 
Septic, arthritis dift'erentiated from 

rheumatic, 420 : endocarditis from 

typhoid, 331. 
Septum ventriculosum. defects in, 

430. 
Serum diagnosis, of syphilis, 98; of 

typhoid. 102, 329. 
Serum, antidiphtheritic, 94, 303 : anti- 

meningitic, 95, 344; of rabbit, in 

hemorrhea, 183. 
Shape of head, semeiology, 4. 
Shiga's bacillus, 194 ; in dvsenterv, 

333. 
Shingles (see Herpes Zoster), 597. 
Shortness of extremities, semeiolog\-, 

51. 
Shower bath, 105. 
Sick-room, 87. 
Sinus-thrombosis, 519. 
Skin, diseases of, 591 ; tuberculosis 

of, 370. 
Skull, semeiologA-, 5. 
Sleep, 83. 
Small-pox, 323; black, 326; confluent, 

326 ; malignant, 326. 
Snuffles, 1, 399. 
Soap bath, 106. 
Sodium, benzoate, 120 ; in influenza, 

290 ; citrate, in cows' milk modifi- 
cation, 70. 
Soor, 185. 
Sore throat, 240. 
Spasmodic, affections, functional, 554 ; 

movements, 52. 
Spasmophilia, 554. 
Spasmus, glottidis, 562; differentiated 

from asthma, 281 ; nutans, 567 ; 

rotatorius, 567; vesicas, 460. 
Spastic, paralysis, semeiolog}', 52 ; 

hemiplegia, 520 ; paraplegia. 536, 

538. 
Spina bifida, 154, 155. 
Spina ventosa, 373, 393. 
Spinal curvatures, lateral, 382 ; in 

adenoids, 245. 



Spinal, hemorrhage, 528; meningitis, 
528; paralysis, 529; paralysis dif- 
ferentiated' from hysterical paral- 
ysis, 587 ; progressive muscular 
atrophy, 545. 

Spinal cord, tumors of, 540. 

Spleen, diseases of, 481 ; movable, 
481; normal, 38, 39. 

Splenic, anemia, 473 ; leukemia, 475. 

Splenitis, acute, 481 ; chronic, 482. 

Splenomegaly, 482. 

Spondylitis, 376; cervical, 377; cer- 
vical differentiated from cervical 
rib, 381 ; dorsolumbar dift'eren- 
tiated from coxitis, 390 ; from 
rheumatism, 418. 

Spotted fever, 338. 

Sprue, 185. 

Sputum, semeiolog}-, 27. 

Staphylococcus vaccine, 96. 

Starting pain, 378, 388, 389. 

Static current, 110. 

Status, lymphaticus, 484; idioticus, 
576. 

Stenosis, and atresia of intestines, 
139; of esophagus, 192; of ostium 
atrioventriculi sinistrum, 431 ; of 
pylorus, 136; of pulmonary artery, 
431 ; of tricuspid valve, 431. 

Sterilization, 72. 

Sternocleidomastoid, hematoma of, 
160. 

Sternum, defects of, 135. 

Stift'ness, of neck, semeiolog}-, 17; of 
vertebral column, 51. 

Stigmata of degeneration, 572, 575. 

Still's disease, 423. 

Stimulants, 118. 

Stomacace, 186. 

Stomach, semeiolog}^ 36; capacity, 
77: diseases of, 193; tube, 107; 
washing of, 107. 

Stomatitis, 185, 186. 

Stools, abnormal, 43 ; normal, 43. 

Stones, in bladder, 460 ; in kidneys, 
454. 

Strabismus, semeiology of, 8. 

Strangulation, intestinal, 213. 

Strawberry tongue in scarlatina, 312. 

Streptococcus vaccine, 96. 

Stridor congenitus, 133 ; dift'eren- 
tiated from spasmus glottidis, 563. 

Struma, 486. _ 

Strumitis, 485. 

Strumous ophthalmia, 372. 

Sublingual growth, 190. 

Sugar-cake liver, 231. 

Sulphur, baths, 106; fumigation, 91. 

Summer complaint (see Gastroen- 
terocolitis), 195. 

Suprarenal extract, 121. 



^18 



INDEX. 



Suspended animation, 165. 

Sutures, cranial, semeiology, 5. 

Sweating in German measles, 296. 

-Syphilis, acquired, 408; congenital, 
hereditary, 398; embryonalis s. 
foetalis, 167, 398; hereditaria lata, 
404; neonatorum, 399; differen- 
tiated from rachitis, 503 ; from 
scrofulosis, 373 ; Wassermann re- 
action in, 98. 

Syphilitic, arthritis differentiated from 
rheumatic, 419 ; dactylitis differ- 
entiated from spina ventosa, 393 ; 
epiphysitis differentiated from 
rheumatic arthritis, 419; from 
scorbutus, 508 ; idiocy, 576 ; laryn- 
gitis differentiated from diph- 
theritic, 311; from simple laryn- 
gitis, 257. 

Syringomyelia, 527. 

Tabes mesenterica, 369. 

Taches, cerebrale, 338; scarlatinale, 
312. 

Tsenise, 223. 

Talipes, 158, 532 ; paralytic differen- 
tiated from congenital, 158. 

Tapeworms, 224. 

Tapotement, 113. 

Teeth, semeiology of, 13 ; Hutchin- 
son's, 405. 

Teething, difficult, 189 ; normal, 13. 

Tendon reflexes, semeiology, 56. 

Tepid bath, 104. 

Testicles, congenital malformations, 
149; undescended, 151. 

Tetanism, 558; differentiated from 
pseudotetanus, 562. 

Tetanus, antitoxin, 95 ; bacillus, 179. 

Tetanus neonatorum, 179 ; dift'eren- 
tiated from pseudotetanus, 562. 

Tetany, 560 ; differentiated from 
pseudotetanus, 562 ; electricity in, 
112; produced by disease of para- 
thyroids, 121. 

Therapeutics, 102. 

Thigh friction (see Masturbation), 
468. 

Thomsen's disease, 549. 

Thoracic muscles, malformation of, 
135 ; regions, 18. 

Thoracoabdominopagus, 145, 146. 

Thorax, activity of, semeiology, 21 ; 
congenital malformations, 135; 
measurements, 20; its contents, 
17. 

Threadworms, 222. 

Throat, diseases of, 239. 

Thrombosis, sinus, 519. 

Thrush, 185. 

Thymitis, 483. 



Thymol, specific in uncinariasis, 229. 

Thymus, death, 484; diseases of, 482; 
hypertrophy, 483 ; gland substance, 
121. 

Thyroid gland, diseases of, 485 ; sub- 
stance, 121. 

Thyroiditis, 485. 

Tinea, favosa, 605 ; trichophytina, 
605. 

Tongue, semeiology, 15 ; diseases of, 
191. 

Tonics, 116. 

Tonsillitis, 240 ; differentiated from 
diphtheria, 309. 

Tonsillotome, 243. 

Tonsils, hypertrophy of, 242; removal 
of, 243. 

Top-milk, 69. 

Torticollis, 250, 381, 418; electricity 
in, 112. 

Trachea, congenital malformations, 
133. 

Tracheobronchitis, 259. 

Tracheocele, 133. 

Tracheotomy, 308. 

Triad, anticostive, 209; of syphilis, 
405 ; of tetany, 560. 

Trichinosis, 425. 

Tricuspid valve, diseases of, 442. 

Trident hand, 504. 

Trismus neonatorum, 179. 

Trousseau's sign, in meningitis, 338 ; 
in tetany, 560. 

Tuberculin, tests, 97 ; therapy, 98. 

Tuberculosis, 351 ; abdominal organs, 
369; bones and joints, 374; brain, 
365 ; elbow-joint, 375 ; genito- 
urinary tract, 370; knee-joint, 391; 
intestines, 369 ; lungs and bron- 
chial glands, 358 ; lymphatics, 373 ; 
metacarpals and phalanges, 393 ; 
miliary, 356 ; prevention of, 352 ; 
skin and glands, 370 ; vertebral 
column, 376. 

Tuberculous, arthritis differentiated 
from rheumatic. 420 ; dactvlitis 
from syphilitic, 407; disease from 
intermittent fever, 412 ; laryn- 
gitis from simple laryngitis, 257 ; 
meningitis from brain tumor, 526 ; 
from non-tuberculous meningitis, 
342; from typhoid, 331; from os- 
teomyelitis, 374 ; from peritonitis, 
366 ; sputum, 360. 

Tumefactions, of extremities, 51 ; of 
neck, 17; scrotum, 49; of thorax, 
21. 

Tumors of, brain, 524; cord, 540; 
kidneys, 456; larynx, 259; liver, 
234; nose, 238; sacrum, 156; 
vertebral column, 51. 



INDEX. 



619 



Turbinated bones, adhesions of, 132. 

Tussis convulsiva, 347. 

Typhlitis, 214. 

Typhus abdominalis, 328. 

Typhoid fever, 328-, differentiated 
from meningitis, 342; from inter- 
mittent fever, 412; from malig- 
nant endocarditis, 439; from 
miliary tuberculosis, 357. 

Typhoid reaction (Grueber-Widal), 
329; diazo, 329. 

Typhoid spine, 330. 

Ulcerative stomatitis, 186. 

Umbilical, arteritis and phlebitis, 180 ; 
granuloma, 174; hemorrhage, idio- 
pathic, 174; hernia, 144. 

Umbilicus, diseases of, 172; care of, 
in the newborn, 173. 

Uncinaria, Americana, 227. 

Undescended testicle, 151. 

Urachus, fistula, 147; persistence of, 
147. 

Uranocoloboma, 129. 

Uranoschisma, 129. 

Uremia, in nephritis, 450 ; in scarla- 
tina, 316; differentiated from 
eclampsia, 555 ; from meningitis, 
342. 

Ureters, congenital malformations, 
148. 

Urethra, congenital malformations, 
149. 

Uric acid, semeiology, 48 ; infarct, 
183. 

Urine, semeiolog}-, 44 ; acetone in, 47 ; 
casts in, 47. 

Urticaria, 594. 

Uvula, semeiolog}^ 16. 

Vaccination, 92 ; contraindications to, 
94. 

Vaccine ophthalmia, 93. 

Vaccinia, 92, 93. 

Vagina, congenital malformations of, 
149. 

Vaginal discharge, semeiology, 49. 

Valvular heart disease, 439. 

Vapor pack. 104. 

Varicella, 321 ; gangrsenosa, 322. 

Variola, 323 : vaccine, 92 ; hemor- 
rhagica, 326. 



Varioloid, 323, 326. 

Ventilation, 87. 

Ventricles, communication of, 430. 

Vertebral column, congenital mal- 
formations, 154; deformities, 
semeiology. 50; normal, 50; tume- 
factions, 51. 

Vertigo, 525. 

Vesical calculi, 460. 

Vincent's angina, 241. 

Vision, disturbance of, semeiology, 8. 

Visual tract, 9. 

Vitellointestinal duct, 146. 

Vitium cordis (see Heart Disease), 
167, 428. 

Vocal resonance, 26. 

Vomiting, semeiology of, 41. 

Vomitus, semeiology of, 41. 

Von Jaksch anemia, 473. 

Von Pirquet tuberculin test, 97. 

Vulva, atresia of, 153. 

Vulvovaginal discharge, semeiology, 
,49. 

Vulvovaginitis, 463 ; gonorrheal, 463. 

Walking, 86. 

Wandering pneumonia, 268; spleen, 
481. 

Warm baths, 105. 

\A^assermann's reaction, 98 ; in svph- 
ilis, 404. 

Water internally, 107. 

Weakness of extremities, semeiologv, 
52. 

Weaning of baby, 80. 

AVeight, chart, 58; of child, 57. 

Werlhof's disease, 479. 

Wet compresses (Priessnitz's), 104. 

Wet. nurse, selection of, 66 ; nursing, 
66. 

Whey, 78. 

White swellings, 391. 

W^hooping-cough, 347. 

Widal reaction, 102 ; in typhoid, 329. 

Winkel's disease (see Hemoglobin- 
uria), 182. 

Wolff-Eisner tuberculin test, 97. 

AA'oman's milk, 60, 68. 

Worms, intestinal, 222. 

Yellow atrophy of liver, acute, 232. 



)Ul 20 1912 



